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Book_ rg>a 

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COPYRIGHT DEPOSIT. 






PEDIATRICS for NURSES 







PEDIATRICS for NURSES 


HI 

JOHN C. BALDWIN, M.D. 

LECTURER IN PEDIATRICS, JOHNS HOPKINS HOSPITAL SCHOOL FOR NURSES; 
PEDIATRICIAN IN CHARGE, FLORENCE CRITTENTON MISSION NURSERY; 
PEDIATRICIAN, BABIES’ MILK FUND ASSOCIATION 



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D. APPLETON AND COMPANY 

NEW YORK :: 1924 :: LONDON 


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COPYRIGHT, 1924, BY 

D. APPLETON AND COMPANY 


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PRINTED IN THE UNITED STATES OF AMERICA 


OCT 11 i924 


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TO 

THE MEMORY OF 
MY FATHER 

FRANK BALDWIN, M.D a 
THIS BOOK IS 
REVERENTLY DEDICATED 






PREFACE 


This is the age of the child. To-day perhaps more than ever 
before our attention is focused on the physical and mental 
health of the new generation. 

When one thinks that in civilized countries at least one child 
in every ten dies during the first year, and that fully one-half 
of these deaths are preventable by proper feeding and care, 
one realizes what an opportunity pediatrics affords for con¬ 
structive medical work. 

With this interest in children, pediatrics has become defi¬ 
nitely separated from general medicine. It occupies itself as 
much with the well child and the preservation of health as it 
does with the sick child. We are learning what food and what 
care are necessary to give the child a fair start in life. And 
this knowledge requires for its application physicians and 
nurses with special training. 

This textbook is the outgrowth of a series of lectures on 
pediatrics which the author has given for the past six years 
to the Intermediate Class of the Johns Hopkins Hospital 
School for Nurses. It is presented in response to many re¬ 
quests that the substance of these lectures be made more avail¬ 
able by being put into book form. The lectures did not aim to 
give a complete knowledge of pediatrics; such knowledge can 
come only in the nursery, the hospital, the milk room, and the 
welfare clinic. They sought rather to give a framework of fact 
and practice about which the nurse could build up her body of 
experience. The same is true of this book. 

A few points of explanation concerning the presentation of 
the material are necessary here. Preference has been given to 
the English system of weights and measures over the more 
scientific metric system. This has been done for very practical 

vii 


PREFACE 


viii 

reasons. Few mothers in this country are familiar enough with 
the metric system to be much enlightened by the statement that 
the new baby weighs 3,500 grams, while 7^ pounds conveys 
a very definite idea to them. Furthermore the scales at our 
disposal outside of the laboratory are usually graduated in 
pounds and ounces. The same can be said with even more 
force with regard to infant feeding. We still buy our milk 
in quarts and pints, and our nursing bottles are still graduated 
in ounces. So there is no good purpose served by thinking and 
talking grams and centimeters when we handle pounds and 
ounces. Conveniently approximate metric figures are given 
for those whose preference lies that way. 

In the same spirit, details of laboratory examinations such as 
blood-counts, serological and bacterial tests and procedures are 
omitted from the discussions of the various diseases, and 
emphasis is laid on that which the nurse herself can see or hear 
or feel. 

Many diseases of childhood are not even mentioned while 
others are only touched upon in passing. This is because it 
has seemed wise to lay the emphasis on those conditions which 
require special nursing care, or in which the procedure is 
radically different from that employed with adults. In this 
connection the illustrations used are those which show nursing 
procedures rather than disease conditions. 

In the selection of his material the author has been greatly 
aided by those nurses who in successive years have assisted him 
in the presentation of his lectures. To these and to Miss Ethel 
Sikes and Miss Helen Giddings who helped him in the prepara¬ 
tion of the illustrations he expresses his profound thanks. 

Finally to Dr. John Howland, Professor of Pediatrics at 
the Johns Hopkins Medical School, he acknowledges a debt of 
gratitude which he can never repay, for his teaching, his sug¬ 
gestions, and his help in the actual preparation of this volume. 

John C. Baldwin 

BALTIMORE, MARYLAND 


CONTENTS 

CHAPTER pAGE 

I. The Normal Infant. 3 

II. The Care of the Normal Baby.17 

III. The Premature Baby.33 

IV. General Considerations of Feeding ... 41 

V. Maternal Nursing.47 

VI. Artificial Feedings.59 

VII. Diets for Older Children.73 

VIII. Diagnostic Methods.79 

IX. Therapeutics of Infancy and Childhood . . 89 

X. Diseases Incident to Birth.103 

XI. Rickets and Scurvy.115 

XII. Digestive Disorders.123 

XIII. Infectious Diseases.137 

XIV. Infectious Diseases (Continued) .... 153 

XV. Infectious Diseases (Concluded) . . . . 171 

XVI. Respiratory Diseases.181 

XVII. Respiratory Diseases (Continued) .... 193 

XVIII. Tuberculosis and Syphilis.205 

XIX. Diseases of the Skin.215 

XX. The Neurotic Child ..225 

XXI. The Convalescent Child.237 
























CHAPTER I 


THE NORMAL INFANT 





CHAPTER I 


THE NORMAL INFANT 

GROWTH 

Growth is one of the most important functions of early 
life. In consequence, questions of growth make up a large 
part of the practice of pediatrics. To recognize a failure on the 
part of the infant or child to gain properly, a knowledge of 
his normal size and rate of growth at various ages is essential. 

In what follows the distinctions between the terms “normal” 
and “average” must be kept clearly in mind. Thus of ioo 
normal newborn babies the weights may vary from 5 to 10 
lb. (2,300 to 4,600 gm.) ; most of them, however, will weigh 
between 6 and 8*4 lb. (2,750 and 3,850 gm.), while the average 
of the whole group will be about 734 lb. (3,500 gm.). In 
other words, a child may vary considerably from the average 
and still be normal. 

Birth Weight. —Boys as a rule weigh slightly more than 
girls. The average weight of boy babies is 7*4 lb. (3,500 
gm.), while that of girls is 7 lb. (3,250 gm.). Those weighing 
under 5 lb. (2,300 gm.) fall into a special group known as 
“Premature Babies.” 

Early Loss of Weight. —Soon after the baby is born he 
starts to lose. This initial loss is due to a number of factors, 
loss of urine, of meconium and of the superficial layers of skin 
being among the most important. About 10 oz. (300 gm.) 
are thus lost in the first three or four days. During these early 
days the food which is received from the mother, and which 
is called colostrum, is scanty, so that the baby receives but 

3 


4 TEXTBOOK OF PEDIATRICS FOR NURSES 

little nourishment. With the arrival of true milk in the 
breasts, however, this loss stops and the child begins to gain. 
His early gain is almost as rapid as was his loss, and by about 
the tenth day the normal infant has regained his birth weight. 

Growth During First Year. —Once he has started to 
gain the normal infant’s weight should show a steady increase. 
A gain of 4 or 5 oz. (100 to 150 gm.) a week is considered 
satisfactory. With such a gain the baby will about double 
his birth weight in the first six months and triple it in a year; 
that is, he should weigh from 14 to 15 lb. (6,500 to 7,000 
gm.) at six months, and from 20 to 21 lb. (9,000 to 9,500 
gm.) when a year old. It frequently happens that vigorous 
breast-fed infants with an abundant supply of milk gain much 
more rapidly, an increase of 2 oz. (60 gm.) a day being not 
uncommon. But it must be remembered that overfat babies 
are not to be desired, and one should be quite content with a 
consistent gain of 4 oz. (100 gm.) a week. But a uniform 
gain after the first year is rather the exception. It is far more 
common for a child to gain rapidly in the spring and fall, and 
show only a very gradual increase during the heat of the 
summer and the shut-in periods of winter. During the third 
year there is a gain of 4 lb. (1,900 gm.), which rate is approx¬ 
imately maintained until the tenth year, when the child weighs 
in the neighborhood of 60' lb. (27.5 kg.). At twelve years 
the average weight is 78 lb. (35.5 kg.), with girls slightly 
heavier than boys for the only time in their career. This is 
due to the fact that puberty is reached somewhat earlier in 
girls than in boys, and that with puberty there is a sudden 
and considerable acceleration in the rate of growth. 

Variations in Weight. —By far the greatest departures 
from average weights are due to feeding. The underfed child 
is always under weight; or the feeding may bring on intestinal 
disturbances which cause the child to lose. Diseases of almost 
every nature have their effect upon weight; minor ailments— 
such as a simple cold in the head—usually checking the rate 


THE NORMAL INFANT 


5 


of gain appreciably, while severe illnesses—such as prolonged 
intestinal disturbances or whooping-cough—exert a profound 
effect on the weight. Heredity, which plays such an important 
part in determining the stature and bulk of the adult, does 
not figure so prominently as a factor in children, and ranks 
below both feeding and disease in determining the weight. 

Height. —While the length of the body is not nearly so im¬ 
portant as the weight, and is much more constant, still it is 
necessary to be familiar with the normal. At birth the average 
length is 20 }4 in. (50 cm.). Babies under 19 in. (47 cm.) 
usually weigh under 5 lb. (2,300 gm.) and are classed as pre¬ 
mature. During the first year the child gains about 8 in. (20 
cm.), during the second year 3*4 in. (8 cm.), and from then 
on about 2 in. (5 cm.) each year until puberty is reached, when 
he shoots up rapidly. 

Variations in Height. —Certain diseases have a marked effect 
in retarding the growth of children. Of these, rickets is the 
most common, while cretinism and a number of rarer condi¬ 
tions also limit growth. The effect of these diseases is noticed 
principally in the length of the extremities, which in childhood 
grow much faster in proportion than the trunk. Heredity plays 
much more of a part here than in the weight of the child, the 
offspring of tall parents tending to grow faster than those of 
short parents. Feeding has relatively little influence on the 
height, however, and it is not unusual to see a child who is losing 
weight during some prolonged illness, actually increase in 
length at the same time. 

The Head. —At birth the head measures 13^ in. (34 cm.) 
in circumference. By the end of the first year this has in¬ 
creased to 17^4 in. (44 cm.)—a gain of 4 in. (10 cm.). 

During the second year, 1 in. (2.5 cm.) is added, after which 
growth is very gradual, being only about >4 in. (1.25 cm.) a 
year until the eighth year, when the head is nearly of adult 
circumference. The very rapid growth in the skull of the in¬ 
fant is made possible by its peculiar structure. Instead of 


6 TEXTBOOK OF PEDIATRICS FOR NURSES 


being a continuous bony shell, it is made up of islands of bone, 
surrounded by cartilage. These plates, which correspond to 
the various bones of the adult skull, are but loosely fastened 
where they meet in the so-called sutures. These sutures are 
so pliable that at birth the edge of one bone often overrides 
another, thus aiding materially in the molding of the head, 
which is necessary in its passage through the birth canal. 
Where the two frontal and two parietal bones meet, there is a 
diamond-shaped, soft spot, known as the anterior fontanel. 
This lies in the midline under the forward part of the scalp, 
and can be seen to move gently up and down with each heart 
beat. Similarly, where the parietal bones and the occipital 
bone come together, there is a smaller, triangular soft spot, 
known as the posterior fontanel. This latter normally closes 
by the end of the second month, while the anterior fontanel 
gradually decreases in size until it finally disappears at about 
the eighteenth month. The closing of the fontanels is delayed 
in rickets, cretinism and hydrocephalus. It is apt to be early 
in malnutrition and microcephalus. 

The softness of the baby’s skull must be kept in mind by the 
nurse. Some infants show a marked preference for lying on 
becomes misshapen, with the side on which the child lies 
one side, and will twist and turn until they get in the desired 
position. If allowed to continue in such a habit the head 
flattened. So one must be careful to turn the baby from side 
to side, and, if the head does become flattened, take pains to 
keep him lying on the opposite side. 

MUSCULAR DEVELOPMENT 

Chest and Abdomen. —These are of about the same circum¬ 
ference as the head until the second year, when the chest grows 
faster than either, and the abdomen faster than the head. 
The health of the baby during the early years has a great in¬ 
fluence on the chest: rickets, tuberculosis and nasal obstruc- 


THE NORMAL INFANT 


7 

tion producing changes, not only in its size but in its shape 
and symmetry, which, however, are not apt to be perma¬ 
nent. 

A baby at birth is unable to make any voluntary movement. 
What coordinated movements he makes—such as breathing 
and sucking—are entirely involuntary reflexes. The hands and 
feet move aimlessly, while the head can scarcely be moved at 
all and unless supported falls heavily to one side. It is usu¬ 
ally three or four months before 
the neck is strong enough to sup¬ 
port the head when the infant is 
held upright. This fact must be 
remembered when handling the 
baby; when holding him over the 
shoulder, for example, one hand 
should be kept high up on his back, 
with the head supported by the 
thumb and the first two fingers. 

By four months also, many babies 
attempt to grasp objects. At first 
this is a very clumsy process as 
the baby has no idea of distance, 
and his muscles work together 
very poorly. He will reach for the Fig. i.—Carrying the Infant. 
moon, expecting as fully to grasp strain, 

it as he will his father’s watch. It 

is not long, however, until he becomes more adept and can pick 
up and wield his rattle in the most approved manner. 

At six months the baby shows a desire to sit up, and by 
seven months can usually sit unsupported for several min¬ 
utes. 

Soon after this many babies start to creep. Creeping is not 
a normal method of locomotion for the human race, and not 
a few babies never practice it. Those who do may adopt any 
of a number of different styles. Some go on hands and feet, 





8 TEXTBOOK OF PEDIATRICS FOR NURSES 


some on hands and knees, while still others sit and hunch them¬ 
selves along with heels and hands. 

Between the tenth and twelfth month most babies learn to 
pull themselves up and to stand with support. 

The age at which they begin to walk varies greatly. I have 
known one baby who walked well at nine months. In general 
boys walk somewhat earlier than girls, and thin babies walk 
earlier than those who are overweight. The average age for 
walking unassisted is one year. It must be remembered that 
when the bones and muscles are strong enough the baby will 
stand and walk. In consequence, it is foolish to try to teach 
a child to walk. This only puts his legs under a strain which 
they are not yet ready to bear, and may easily result in bow¬ 
legs or knock-knees in children suffering with rickets. 

SPEECH 

Most babies will begin to talk at about one year. The first in¬ 
telligible words are usually “mama” and “papa”; soon they 
acquire other proper names, then the names of objects. By two 
years they are usually putting words together into sentences. 
A child who makes no effort to talk at this age should be care¬ 
fully examined to determine whether he may be a deaf-mute. 
If he can hear but does not talk, it is very probable that he 
is mentally retarded. One should never encourage a child to 
continue the use of “baby-talk” by imitating him. Always 
speak as distinctly as possible so that he may imitate you, for 
bad habits of speech soon become fixed and are embarrassing 
both to child and parent, when they persist to the school age, 
as they frequently do if not firmly checked. 

SPECIAL SENSES 

Our senses—sight, hearing, touch and the rest—are the most 
delicate of mechanisms, and it takes the newborn infant some 
time to get them into working order. 


THE NORMAL INFANT 


9 

Sight. —It is usually three or four months before the eyes 
move in unison, and a mother with her first-born has hours 
of dread, when she sees the baby’s eyes wandering quite in¬ 
dependently of each other, for fear her child will be cross¬ 
eyed. Even the lids do not function properly, and it is not 
uncommon to see a normal infant sleeping with eyes half 
open. The eyes are also unduly sensitive to bright light and 
the infant appears distressed when exposed to it. This must 
be kept in mind in caring for young babies. In the nursery, 
the infant should be protected from the direct rays of the 
sun, and when out in his carriage the hood should be lowered 
on bright days. 

Hearing. —The child is practically deaf at birth, but he 
soon begins to hear, and by the time he is a month old will 
jump, as though frightened, at any sudden noise. By the time 
he is six or seven months old he can recognize familiar voices. 

Pain. —The senses of touch and pain are very dull at first, 
so much so that minor surgical operations—such as circum¬ 
cision—can readily be carried on without an anesthetic. 

Taste. —Of all the senses taste seems to be the best devel¬ 
oped at birth. I knew one baby who would not take water 
from the city supply, but would drink that from a spring in 
a near-by park. And I was never able to fool him by chang¬ 
ing the bottles and nipples from which the two samples were 
taken. 

Smell. —The sense of smell develops late; it is said that finer 
distinctions are not made until late in childhood. 

TEETHING 

The Teeth. —At birth the teeth lie against the jaw bones, 
deep in the gums. Soon after birth the roots begin to grow 
and press against the jaw. This forces the crowns upward 
toward the gum margins. Little by little they work their way 
through the firm tissues and finally break through the mucous 


IO TEXTBOOK OF PEDIATRICS FOR NURSES 


membrane. The first teeth to appear are the lower middle 
incisors, which usually come through at about the sixth month. 
At from eight to twelve months the four upper incisors ap¬ 
pear. At one year of age the child will thus have six teeth. 
During the next three months he gets the lower lateral in¬ 
cisors and the first molars. This leaves a gap, which is filled 
at from eighteen to twenty-four months by the canines, other¬ 
wise known as the eye-teeth (above) and the stomach-teeth 
(below). Finally between two and two and a half years, the 




C7C70fTT? moor? 

5 3 4 3 "HU 3 4 3 5 

Fig. 2.— Diagram of Deciduous Teeth. 

1. Lower middle incisors 6-8 months 

2. Upper incisors 8-12 “ 

3- Lower lateral incisors and anterior molars 12-18 “ 

4. Canines 18-24 “ 

5. Posterior molars 24-30 “ 

four back molars come through. These twenty teeth con¬ 
stitute the first set, which are known as the deciduous or milk- 
teeth, and are all the child gets until he is about six or seven 
years old. 

Difficult Dentition. —From what has just been said it is seen 
that from the time a child is born until he is two and one-half 
years old he is constantly in the process of teething. Formerly 
most of the ills to which a child fell heir during that period 
were laid to teething. If the baby had a convulsion, it was 
blamed on the teeth; if he had diarrhea or vomited, it was due 
to the teeth. Even to-day ignorant mothers will often com¬ 
plain that the baby always teeths with “running ears” or with 



THE NORMAL INFANT n 

a “cough.” However, as more has been learned about babies 
from year to year, one after another of these ailments has been 
shown to have its own particular cause, in no way related to 
the eruption of the teeth. So that now there remain but a 
few minor manifestations which can with any justice be attrib¬ 
uted to teething. For a few days before the tooth actually 
breaks through the mucous membrane, the gums are red and 
swollen. During those days the baby may be slightly fever¬ 
ish and fussy and take his feedings poorly. But very often 
the first intimation which one has that the teeth are on their 
way is the appearance of the teeth themselves. 

Irregular Dentition. —There are very wide variations from 
these normals. As a rule, breast-fed children teeth earlier and 
more easily than the artificially fed. Infants are sometimes 
born with teeth. This is unfortunate, as they often interfere 
with nursing and have to be extracted. Syphilitic children 
often teeth early, and the teeth are apt to decay long before 
the second set is ready to appear. Very many normal children 
get their teeth in a different order from that outlined above. 
In mentally defective children, the dentition is usually irregular 
in sequence, and is apt to be irregular in arrangement. In 
rickets, dentition is invariably delayed. 

The Second Set. —The first of the permanent teeth to appear 
come in behind the second molars of the first set. They are 
known as the “six-year molars,” from the time of their erup¬ 
tion. Then comes the ugly stage of childhood, when the sec¬ 
ond teeth pushing upward cause the first to loosen and drop 
out. First the permanent incisors replace the deciduous in¬ 
cisors. Then the second canines replace the first. The original 
molars have their places taken by eight bicuspids. Then be¬ 
hind the six-year molars come in the second molars, which 
usually appear at about fourteen years of age. Finally at 
about twenty years the third molars, or “wisdom teeth,” make 
their presence known. 


12 TEXTBOOK OF PEDIATRICS FOR NURSES 


SLEEP 

Hours. —The newborn infant spends practically all of his 
time in sleep. For the first two or three days the sleep is 
almost continuous. During the first six months he is awake 
but little, except for his feedings and bath, which means from 
twenty to twenty-two hours of sleep each day. At a year he 
should sleep twelve hours at night, with one interruption for 
nursing, and should take two naps, totaling two or three hours. 
By the time he is from fourteen to sixteen months the night 
feeding can usually be omitted, so that he has an unbroken 
sleep of twelve hours. At two years he will be taking but 
one nap a day, usually of about two hours, and will be sleeping 
from seven at night until six in the morning. The daily nap 
usually becomes difficult to obtain in the fourth year, and may 
be dropped, except in the case of high-strung, easily fatigued 
children, who should be required at least to lie down for a time 
after luncheon until they are six or seven. 

Regular Habits. —Children vary in the amount of sleep they 
require, and one should always be sure that the child gets 
enough. He is very unlikely to sleep more than is good for 
him. It is extremely important that the child be trained early 
into regular habits of sleep, for nothing is so difficult as taking 
care of a child who insists upon turning night into day, as 
many of them will, if not properly trained. The baby does 
much better, as a rule, if he sleeps in a room by himself. At 
all events he must have a bed to himself. The practice of 
Bleeping in the bed with the mother should be forbidden as 
dangerous and unhealthy. If a baby has been properly trained, 
all that is necessary at bedtime is to put him in bed, darken the 
room and leave him. A well baby who is dry, warm, and 
well-fed promptly falls to sleep. On the other hand, if he is 
accustomed to being rocked or sung to, he will not go to sleep 
normally, and makes constant and unnecessary demands on 
the time of his nurse. Such a child is particularly difficult 


THE NORMAL INFANT 


i3 

when some illness has made him fussy and wakeful. Then 
the rocking or walking becomes a continuous process. 

The Bed. —For the first few months of life a bassinet is the 
best bed. It should be light so that it can be easily moved 
about and should be free from flounces and draperies, which 
are hard to keep clean and invite dust. A clothes basket, with 
a quilted lining and a fairly firm pillow as mattress meets these 
requirements well. It may be placed on two chairs to bring it 
to a convenient height. By two months the baby may graduate 
to a crib. The most convenient type is of white enameled iron, 
and has one or both sides so arranged that they may be let 
down. This enables the child to be cared for without reaching 
over a high side. If there is a choice, a higher crib is better 
than a lower, as one does not have to stoop so far in handling 
the child. For hospital use, where the patient has frequently 
to be examined, the crib in which the spring and mattress may 
be raised to the height of the sides, with the patient on them, is 
almost a necessity. 

The bed should be made up with a rubber sheet, linen or 
muslin sheet and quilted pad under the baby; over him should 
be a sheet, enough warm, light blankets and a light spread. 
In cold weather a light quilt may be used in addition. A 
pillow, if used at all, should be thin. An ordinary pillow¬ 
slip, folded until about ten inches square, serves admirably. 











t 




fc 








I 













CHAPTER II 

THE CARE OF THE NORMAL BABY 




























































































































































* 




















* 










































- 















♦ 















































CHAPTER II 


THE CARE OF THE NORMAL BABY 

At Birth. —The care of the infant at birth falls in the 
province of the obstetrical nurse, but an outline of that care 
may well be given here. As soon as the cord is tied and 
cut, a dry sterile dressing is applied to the stump. The child 
is then wrapped in soft, warm blankets and placed in a basket 
or other convenient place, and surrounded with hot-water 
bottles. There he is left until time can be spared from the 
mother to give him further care. From the moment of his 
birth, however, the baby must be watched to be sure that he 
cries vigorously and breathes well. At the first suggestion of 
cyanosis or shallow, insufficient respiration, the baby must be 
made to cry. The importance of this will be further empha¬ 
sized in Chapter X. As soon as the time can be spared, further 
attention is given the child. The skin, which at birth is covered 
with a sticky coating known as the “vernix caseosa,” is care¬ 
fully cleansed with olive oil on soft cloths. This should be 
done in a warm room, preferably before an open fire, and 
with as little exposure of the baby as possible. The mouth is 
then cleansed with sterile water and sterile pledgets of cotton. 
Finally, and most important of all, the physician should drop 
into each eye one or two drops of a fresh 2 per cent solution 
of silver nitrate. It is not always an easy matter to get the 
drops into an eye which the infant instinctively keeps tightly 
closed. But one should never be satisfied until he is certain, 
beyond any doubt, that he has actually succeeded in getting 
the solution into the eye. There is no possible excuse for 
failure to carry out this step satisfactorily, as it is harmless 
in itself, and, if neglected, may and often does lead to blind- 

17 


18 TEXTBOOK OF PEDIATRICS FOR NURSES 


ness. The nurse should never hesitate to remind a physician 
of his oversight, if through carelessness or pressure of some 
emergency he has neglected to put drops into the baby’s eyes. 

After these details are attended to, the baby is weighed, 
measured, dressed and put in his basket, and placed in a quiet, 
warm, dimly lighted room. If he has shown the least indica¬ 
tion of not breathing satisfactorily, he should be carefully 
watched. After six hours, if the mother has sufficiently re¬ 
covered from her ordeal, the baby is placed at the breast. This 
should be repeated each six hours during the first day, and 
thereafter every four hours. Between feedings the baby may 
be given warm, boiled water, from ]/ 2 to 2 oz. (15 to 60 c.c.) 
if he is fretful. 

The infant should not be given a tub bath until the cord has 
separated, which usually has happened by the eighth day, often 
by the fourth or fifth day. 

The Bath. —In considering the daily bath, some discussion 
of the paraphernalia required is needed. In hospitals with 
their special warm rooms, with high table, tubs and sprays, the 
bath is simple, but in private homes considerable ingenuity is 
sometimes necessary to provide suitable surroundings for the 
bath. 

It is well to have a white enamel tray or basin to hold small 
toilet articles. This is not as dainty-looking as the lace- 
trimmed bath baskets on the market, but it is just as convenient, 
much less expensive and very much more sanitary. On the 
tray should be: 

Absorbent cotton pledgets in covered- glass jar 

Eottle or jar of boric acid solution 

Small, enameled bowl 

Bottle of albolene 

Toothpick swabs in covered jar 

Celluloid soap box 

Box of baby powder 

Tube of vaselin or bottle of olive oil 


THE CARE OF THE NORMAL BABY 


19 


Assorted safety pins 

Scissors 

Hairbrush 

Bath thermometer 

It is very tiring and unnecessarily difficult to give a baby a 
bath in the family bathtub. There are many useful types of 
infant tubs on the market, perhaps the best of which is made 
of rubber sheeting on a light, wooden frame. This tub may 
be folded and put away when not in use; when wanted, it may 
be set up on a table, or across the top of the family tub. 

The room in which the bath is given should be warm and 
free from drafts. In cool weather, an electric heater is useful 
and furnishes a delightful glow. 

The nurse should have a large apron of rubber sheeting to 
protect her uniform; over this should be a soft bath apron 
of outing flannel or stockinet. She should have a low, com¬ 
fortable rocking-chair, without arms, in which to sit, and 
there should be a low table on which to place the bath tray. 
She requires several very soft, turkish towels or old bird’s- 
eye diapers, and two or three soft cloths for washing the 
baby. 

The water for the bath should be clean and not too hard. 
Hard water is apt to make the skin crack and should not be 
used with young babies. In localities where the water is hard, 
one may either use rain water or boiled water for the bath. 
The temperature of the bath should not be guessed at. It 
should be measured with a bath thermometer and brought 
accurately to the desired point by pouring in hot or cold water 
as the case may be. If one has no thermometer, the bend of 
the elbow is a better guide than the hand, as its natural sensi¬ 
tiveness has not been impaired by frequent emersions in hot 
and cold water. 

The temperature of the bath for the first two months should 
be ioo° F. Subsequently this may drop a degree a month until 
at six months it is 95 0 F.; at one year, 90° F. 


20 TEXTBOOK OF PEDIATRICS FOR NURSES 


The soap used should be some bland, unscented, unmedicated 
variety. White Castile or Ivory are satisfactory. 

Bath Preliminaries .—Immediately before the bath proper 
there are a number of minor details of the toilet which must 
be carried out. The nose should be cleansed of any crusts 
or mucus by the use of toothpick swabs dipped in albolene. 
Any secretion in the corners of the eyes, or on the lids, should 
be gently wiped off with a pledget of cotton soaked in boric 
acid. The attention of the physician should, of course, be 
called to any considerable discharge from the eyes. The mouth 
should not be cleansed. Thrush is very much more common 
in babies whose mouths are washed daily than in those whose 
mouths are unwashed. The outer ear may be cleansed, and 
any wax which oozes from the canal may be wiped away, but 
nothing should be introduced into the canal itself. The deli¬ 
cate structures of the middle ear lie SO' close and are so easily 
damaged that it is unwise to take any chances of injuring 
them. If the canal needs cleaning it should be done by the 
physician. 

Toilet of Genitalia .—If the infant is a boy, the foreskin 
should be drawn back and the parts gently sponged with boric 
acid, after which the foreskin should again be slipped forward. 
If the foreskin is unusually long, or has a small opening, or 
is adherent to the head of the penis so that retraction is diffi¬ 
cult, it is wise to wait until the trouble is corrected by the 
physician. 

It sometimes happens that the foreskin slips back fairly 
easily but after the washing does not come forward readily. 
In a short time the foreskin becomes congested and edematous, 
and the more swollen it becomes the harder it becomes to re¬ 
place it. If this accident happens, the following method will 
generally right matters: The first and second figures of the 
right hand are placed behind the swollen foreskin, while the 
ball of the thumb presses upon the head of the penis. Gentle, 
steady pressure is exerted by the thumb, the effort being made 


THE CARE OF THE NORMAL BABY 


21 


to push the head back through the swollen collar of foreskin. 
Usually in a very few minutes the foreskin slips forward, 
and in half an hour or so the swelling has subsided. If this 
method should not prove successful, the physician should be 
summoned, as prolonged pressure of this constricting band 
may cause damage. 

In bathing girl babies, the labia should be held gently apart, 
and a piece of cotton soaked in boric acid used to cleanse the 
mucous membranes. Care must be taken that the washing 
is toward the rectum, not away from it, as it is obviously 
unwise to carry any possible contamination from the rectum 
to the vagina or urethra. Any unnatural redness of the parts 
or secretion from the vagina is of importance and should be 
brought to the notice of the physician. 

The Bath Proper .—When these details have been disposed 
of, the scalp is washed with soap and water, rinsed and dried. 
If there is much dandruff, or any scaly deposit on the scalp, it 
should then be anointed with a little vaselin or olive oil. The 
face is then washed with clean water and a fresh cloth and 
dried. No soap is used on the face. The rest of the body is 
then washed with soap and water, and the infant is ready for 
the tub. In placing him in the tub it is well to put the fingers 
of the left hand in the baby’s left axilla, holding firmly to the 
shoulder with the left thumb. The baby’s head then rests 
against the forearm. He is grasped under the knees with 
the right hand and lowered into the tub. The right hand is 
now free, while the left continues to support the baby, and 
prevents him from slipping down under the water. He is 
quickly rinsed and removed from the tub. 

Cool Sponge .—After eighteen months, vigorous babies may 
have the warm bath followed by a shower or a rapid sponge 
with water at 70° F. The baby must react well to this—that is, 
he must be rosy and animated. If he seems cold, and his lips 
and finger tips are bluish, this part of the bath must be dis¬ 
continued. 


22 TEXTBOOK OF PEDIATRICS FOR NURSES 


Drying .—After the infant is removed from the tub, he 
is placed on a soft towel in the nurse’s lap and is gently patted 
with another until dry. Great care must always be taken that 
all of the deep folds and creases are perfectly dry, otherwise a 
very annoying irritation may be set up. When the baby is 
satisfactorily dry, he may be lightly powdered wherever two 
skin surfaces come together, as about the neck, under the arms, 
about the buttocks and genitalia, and, in very fat babies, under 
the knees. For this purpose a good, unscented talcum powder, 
stearate of zinc or fine cornstarch should be used. The baby 
is then dressed, his hair brushed and he is ready for the day. 

Extra Baths .—The foregoing description applies to the 
daily cleansing bath. In addition, it is frequently desirable to 
give the baby others. This is particularly true in very hot 
weather, when the baby is made much more comfortable by 
sponging him off with tepid water once or twice during the 
afternoon and evening. Also it is frequently necessary to 
give him an impromptu bath when he has had a stool which 
has gone unnoticed for a time, so that the fecal matter has 
become widely distributed. The same care must be exercised 
after these baths, as after the morning tubbing, to dry the 
skin thoroughly. For only in this way can one prevent irrita¬ 
tion. 

Care of the Nails. —The finger nails and toe nails should 
be frequently trimmed with scissors. The latter should always 
be cut straight across, leaving the corners at least as long as the 
rest of the edge. In this way the chance of ingrowing toe¬ 
nails is much lessened. The nails should be cleaned daily 
with a toothpick wound with a wisp of cotton. 

Care of the Teeth. —It is a frequent mistake to neglect the 
first teeth on the ground that they are only temporary and it 
makes no difference if they do decay. As a result, it is not 
uncommon to see children of four or five years with numbers 
of decayed, broken and badly stained teeth. This affects the 
child harmfully in a number of ways. It causes him pain and 


THE CARE OF THE NORMAL BABY 


23 


discomfort. It frequently impairs the digestion by making it 
impossible for him to chew his food properly. It very much 
increases the likelihood of his developing large, diseased ton¬ 
sils, by increasing the number of bacteria in the mouth. And 
finally it has a harmful effect on the second dentition, the teeth 
frequently coming in irregularly as a result of losses in the 
first set. The remedy is to care for the first set as diligently 
as the second. As soon as the first teeth make their appearance, 
they should be carefully brushed twice each day with a very 
soft toothbrush. If the teeth are at all stained, a few drops 
of milk of magnesia on the brush will prove helpful. When 
all the teeth are through a fairly stiff brush may be used. 
By the time a child is four he should be taught to brush his 
own teeth. At this age a pinch of any of the good tooth 
pastes on the market may be used on the brush, and usually 
adds very much to the eagerness of the child to care for his 
teeth. He should, of course, be supervised to make sure that 
he is regular in his brushing and that he does not neglect 
his back teeth. From time to time the teeth should be carefully 
inspected, and at the first show of decay he should be taken 
to a dentist. It is in fact not a bad plan to make a periodic 
visit to the dentist part of the routine of the life of every 
child. This can be started at two years and continued every 
six months thereafter. Special attention should be paid to 
the teeth during the transition from the first to the second set. 
The six-year molars, which are the first of the permanent teeth 
to come through, very frequently develop small cavities in the 
center of the grinding surface. These cavities should be prop¬ 
erly treated as soon as discovered, because they grow with 
great rapidity. If the teeth are irregular in arrangement, the 
advice of a dentist specializing in that type of work should be 
sought. 

Airings.— Next to his food, no one factor has such an effect 
on the well-being of a child as the amount of sunshine and 
fresh air which he gets. The age at which an infant may go 


24 TEXTBOOK OF PEDIATRICS FOR NURSES 

outdoors depends upon the season at which he is born, and 
the first outing should always be sanctioned by the physician. 
But, as a rule, healthy infants born in summer may begin their 
outings when a week old, while those born in the winter may 
frequently start at a month. At first, the time spent outdoors 
should be brief, but as the child becomes used to it the stay 
may be lengthened, until in warm weather the baby is out 
almost continuously, while during the cold season he is out for 
two or three hours on pleasant days. The child should not 
be taken out in extremely cold weather, or when there are high 
winds, or on cold, moist days. Likewise in the very hot 
weather it is often more pleasant indoors during the heat of 
the day. Delicate children born during the spring and fall, 
and even robust children in very bad winter weather, are often 
benefited by indoor airings. They are dressed as if to be taken 
out, placed in the carriage, covered with warm robes. The 
windows of the room are then opened. In this way the baby 
gets considerable outdoor air with a maximum of protection. 
It is easy in this way to accustom a baby to the cold so that 
he may be safely taken outdoors. 

Exercise.— The newborn infant gets his exercise by crying. 
Soon, however, he adds to this kicking and waving of the arms. 
It is important that this tendency to exercise should not be 
checked by clothing which hinders free motion. When a child 
is three or four months old it is advisable to have a definite 
time each day when he is placed on a bed in a warm room, 
with diaper off, and encouraged to kick. When he begins to 
sit and creep, it is well to place him on a quilt on the floor 
so that he may have a firm surface on which to exercise. 
When he begins to walk, a pen with heavy canvas floor, which 
can be placed over a quilt, is desirable. In this way the aver¬ 
age baby in the home gets all the exercise he needs. In hos¬ 
pitals and other institutions for children, however, this is 
unfortunately not the case. The infants are handled less, 
they are talked to less, and, if care is not taken, they become 


THE CARE OF THE NORMAL BABY 


25 

apathetic, lose their appetites and go steadily down hill. It 
is largely for this reason that babies do not do well in insti¬ 
tutions. They need “loving,” which unfortunately cannot be 
administered wholesale. Such infants should get their exercise 
passively; they should be picked up frequently; they should be 
talked to; they should have their position changed frequently, 
and they should be given gentle massage at the time of bath, 
and perhaps once again during the day. With such care many 
of them can be saved who would otherwise die. 

Training of Bladder and Rectum. —A nurse who is caring 
for babies should consider it a part of her task to institute 
and cultivate regular habits in the babies. This applies to 
feedings, sleep, bath, airings—everything that has to do with 
the daily life. She should take special pains in training the 
bladder and rectum. This training really starts at birth, and 
at first consists of simply changing the diaper whenever wet 
or soiled. Soon the child learns to cry when the diaper needs 
changing. This is the first step. By the time he is four or 
five months old, and can hold his head up well when the trunk 
is supported, he may be taught to have his movements in a 
chamber. This is accomplished by holding the infant upon a 
warmed chamber at those times at which he usually soils his 
diapers. For the first time or two it may be necessary to “sug¬ 
gest” to him what is wanted by means of a soap stick. Very 
soon, however, an infant of normal intelligence learns to 
associate the chamber with evacuation of the bowels. The 
trouble necessary for this training is well repaid by the subse¬ 
quent ease in caring for the child. And this habit of regularity, 
if acquired early, is one of the surest guarantees against consti¬ 
pation in later life. 

Training of the bladder is not so easy and is rarely success¬ 
ful before the tenth or twelfth month. It is best carried out 
by placing the child on the chamber at frequent, regular inter¬ 
vals, depending on how often he is accustomed to urinate. 
Usually one may start by putting the child on his chair every 


26 TEXTBOOK OF PEDIATRICS FOR NURSES 

hour. If he keeps dry for several days with this routine, the 
time may be increased to an hour and a quarter, and so on 
until he is keeping dry for two hours at a stretch. He will 
soon learn to make his wants known, if sometimes he cannot 
go the allotted time. This training is more difficult at night. 
It is. of course, too much to expect of a baby who is getting 
8 oz. of milk at 6 P.M. and another 8 oz. at io P.M. to stay 
dry throughout the night. And it is too much to expect of the 
nurse, or mother, to get up every two hours to place him on a 
chamber. Little can be done, in consequence, until the io P.M. 
bottle is omitted—usually at about fourteen months. At that 
age, however, training should be begun. The baby should be 
picked up at ten or eleven. If the day training has been suc¬ 
cessful, when the bladder again becomes full, say at two or 
three in the morning, the baby will become fussy, or cry out, 
and can again be taken up. By the time he is three years old, 
he will frequently go through from ten at night until six 
in the morning. It is usually necessary to pick the child up 
when the mother or nurse goes to bed until he is about five 
years old, after which he will generally sleep comfortably from 
his bedtime until morning without voiding. 

CLOTHING 

The comfort of an infant depends in no small degree on the 
way in which he is clothed. Whole races sometimes go astray 
in their habits of clothing children, with consequent discom¬ 
fort to the child and detriment to fhe race. Witness the 
Italian bambino, bound so tightly he cannot move hand or 
foot; the Chinese girl with her bandaged feet, and the English 
and American youngster with bare knees in the winter weather. 
The requirements of proper clothing are that the garments 
shall be loose, light, well-fitting and sufficiently warm in 
winter and cool in summer. In addition, it is wise to have 
them as simple and easy to put on as possible. 


THE CARE OF THE NORMAL BABY 27 

The Band. —The use of the flannel binder seems to be 
firmly rooted, though what good purpose it serves after the 
umbilicus is healed is hard to see. It is difficult to apply, it 
will not stay where it belongs—either slipping down so as to 
get wet, or slipping up so as to hinder respiration. If tight 
enough to give support to the abdominal muscles, it causes 
unnecessary pressure upward on the diaphragm and down¬ 
ward, increasing the possibility of inguinal hernia. In other 
words, it is better left off, and its place taken by a knitted 
band of silk and wool, with shoulder straps, and tabs to which 
the diaper may be pinned. 



Fig. 3.—Triangular Diaper. 


The Diaper. —The principal requirements of the diaper are 
that it shall be absorbent and soft. The regular cotton diaper 
materials, such as bird’s-eye, are probably the best. There 
are many ways of applying the diaper, of which the two given 
here seem the best. 

The Triangular Diaper with Pad .—A large diaper is folded 
diagonally into a triangle. Over this is laid a second smaller 
one, folded into an oblong. In place of this second diaper, a 
soft, folded paper towel may be used, and will save much 
disagreeable labor, as it can be thrown away when soiled. 
This combination is applied so that the pad covers the buttocks 
and genitalia, the folded edge of the larger diaper goes snugly 




28 TEXTBOOK OF' PEDIATRICS FOR NURSES 


around the waist, while the other corner is brought up between 
the thighs, the whole being secured with three safety pins, one 
fastening the two corners to the tab on the band, the other 
two bringing together the edges so as to encircle the thighs. 

The Square Diaper .—This arrangement is not so easy to put 
on and cannot be made to look so neat. It has the advantage, 
however, of being less constricting, and is to be recommended 
for boy babies. A large diaper is folded into such a square 
that the upper edge will a little more than half encircle the 
waist. The lower edge is then brought forward between the 



Fig. 4.—Square Diaper. 


thighs, and the corners pinned to the corners of the upper 
edge. Two more pins hold the edges snugly about the thighs. 

Laundering the Diapers .—Wet or soiled diapers should not 
be kept in the nursery. There should be separate pails for 
them in the bathroom or other convenient place. A soiled 
diaper may sometimes be partially emptied into the toilet on 
being removed. It is then placed to soak in its pail, which 
contains some water, and the lid is tightly closed. Once or 
twice a day all of the used diapers should be thoroughly washed 
with soap, and rinsed in several changes of clear water. They 
should then be thoroughly aired and dried. 

The Rubber Diaper Cover .—This cannot be criticized too 
strongly. It results in the baby lying in a puddle, and is a very 




THE CARE OF THE NORMAL BABY 


29 

common cause of irritation on the buttocks. The only time it 
can be justified is when traveling. 

The Shirt. —Over the band goes the shirt. This should be 
of silk and wool in winter, and of cotton in summer. It is 
made with long sleeves, is cut high in the neck and buttons 
or ties down the front. It should be large enough to fit loosely 
even after shrinking. 

The Petticoat. —This should be made with a. white flannel 
skirt on a loose-fitting, sleeveless waist of muslin. In young 
infants it should come four or five inches below the feet. 
Too often this garment is made snug in the waistline, where 
it should be full. A very convenient petticoat has buttons and 
buttonholes on the shoulder straps. This saves the trouble of 
getting the arms through the armholes. 

The Dress. —Taste and pocketbook will determine the type 
and material of the outside dress. It reaches an inch or so 
below the petticoat, and should be of some light, easily washed 
material. The simpler it is, the cleaner it will keep and the 
more easily it will be laundered. 

Covering the Feet. —Loose socks or knitted booties should 
be worn in cold weather and at other times if the feet have 
a tendency to become cold or blue. 

Night Clothes. —The baby has a complete change of clothing 
on being put to bed for the night. It consists of band, diaper 
and shirt, as in the day, and over these the nightdress. This 
is made of any of a number of materials and is long and loose. 
In very cold weather heavier material may be used, while in 
summer a very light weight is desirable. 

Clothing in Summer. —It is my experience that very few 
infants are underclothed, while in hot weather most are very 
much overclothed. During the hot, humid days of summer 
babies suffer extremely, and are particularly liable to digestive 
upsets. In order to make them as comfortable as possible, 
they should be very lightly clothed. First the petticoat should 
be discarded, then the shirt, while in exceptionally hot weather 
the diaper and band are none too little. 


























































































































































































» ■ 
























' 

























CHAPTER III 

THE PREMATURE BABY 












CHAPTER III 


THE PREMATURE BABY 

There is no type of case in which good nursing is as essen¬ 
tial as in the care of the premature infant. Without an intelli¬ 
gent and cooperating nurse, the physician’s best efforts are 
largely wasted. In fact the outlook in these cases depends 
very materially on how soon after birth the infant is placed 
in the hands of such a nurse. 

The group which we speak of as “premature babies” has 
no sharp limits. It comprises, roughly, babies who at birth 
weigh under 5 lb. (2,300 gm.), who measure under 19 in. (47 
cm.) or who are unusually feeble from some other cause. 
Most of them, of course, are born before term. Their appear¬ 
ance is quite characteristic. The skin has a peculiar waxy 
transparency. The muscles are very weak SO' that the child 
lies relaxed and practically motionless. The breathing is 
shallow and irregular, and the cry but a feeble whine. The 
smaller ones are quite unable to nurse satisfactorily, and 
some are even too weak to swallow well. These infants chill 
easily and, unless artificial heat is applied, their temperature 
falls below normal. Furthermore, they have but little resist¬ 
ance to disease, and even minor infections frequently prove 
fatal. In consequence there are three main problems in their 
care: to nourish them successfully, to maintain a normal tem¬ 
perature and to avoid infection. 

Nutrition. —Breast milk is the only satisfactory substance 
on which to feed the premature. This complicates matters, 
as the mothers of infants born much before term seldom have 
an adequate supply. In consequence it is usually necessary 
to obtain milk from a wet-nurse. Furthermore these patients 

33 


34 TEXTBOOK OF PEDIATRICS FOR NURSES 

are seldom strong enough to nurse from the breast, and so some 
easier way for them to get the milk must be found. Having 
obtained milk from the mother or nurse (see chapter on 
Maternal Nursing for methods of obtaining milk), the best 
way to give it is usually with the Boston Feeder. This is a 
graduated glass tube holding i or 2 oz., having a small nipple 
attached to one end and a rubber bulb at the other. The milk 
at the proper temperature is placed in the tube, the nipple is 
given to the infant, and his feeble efforts at sucking are aug¬ 
mented by gentle pressure on the bulb. Some infants are too 
weak even to be fed in this way, and must get their food by 
gavage. This is accomplished by passing a small rubber tube 
through the mouth into the stomach, and slowly pouring the 
required amount of warmed milk into it. As the strength of 
the baby increases, the Boston Feeder is substituted for 
gavage, and later the ordinary nursing bottle or the breast 
takes the place of the Boston Feeder. 

Feedings should be given regularly every three or four 
hours. At first only very small amounts should be given— 
perhaps y 2 oz. (15 c.c.) at a feeding, this quantity being gradu¬ 
ally increased until a sufficient amount is given so that the child 
may gain. Thus a baby weighing 3 lb. will need from 
to 1 J / 2 oz. (35 to 45 c.c.) of breast milk every four hours, 
while a 5-lb. infant will need 2 oz. (60 c.c.) every four hours. 

Maintenance of Body Temperature. —In order to keep the 
premature baby’s temperature within normal limits consider¬ 
able ingenuity and great watchfulness are necessary. In some 
cases, a special apparatus called an “incubator,” is used for 
the purpose, but it is costly, gets out of order easily, and re¬ 
quires special care to operate, so that it has been largely dis¬ 
carded for simpler means. Many hospitals which care for 
prematures have special “warm rooms” where these delicate 
infants are kept. These rooms are arranged so that the 
temperature may be kept constant at from 85° to 90°, and 
so that the air may be kept fresh. The clothing also is designed 



THE PREMATURE BABY 35 

for warmth. A particularly good type of premature jacket is 
made of absorbent cotton, covered with gauze and quilted. 
It has a hood for the head, opens down the front and is Ion 
enough to cover the baby entirely. This permits of examinin 
.or changing the baby with a minimum of exposure. The usual 


Fig. 5.—Jacket for Premature Infant. 

diaper may be used, or, in its place, a pad of cotton may be 
placed under the buttocks and about the genitalia. These 
should be changed when wet or soiled, exactly as with normal 
infants. A soft, warm blanket, in which the infant, clothed 
in his jacket, may be wrapped, completes the wardrobe. 

In the home, where no “warm room” is available, the pro¬ 
cedure is somewhat different. A small crib, or clothes basket, 


crq crq 





36 TEXTBOOK OF PEDIATRICS FOR NURSES 

is provided with heavily padded sides. In this is placed the 
mattress or a fairly hard pillow. The baby is anointed with 
olive oil and covered, except for the face and buttocks, with 
sheets of absorbent cotton which are changed every other day. 

Day of 
Disease 

Temp. 

109 

108 

107 
106 

105 

104 

103 

102 

101 

100 

99 

98 

97 

96 

95 

94 

Fig. 6.—Temperature Chart of Premature Infant. Patient showed a 
low temperature on admission, with wide variations for first 4 days, after 
which temperature remained within normal limits. 

A separate pad of cotton which can be changed as necessary is 
placed over the buttocks and the child is wrapped in a soft 
blanket. He is then placed in the basket and several hot-water 
bags are laid around the edges of the mattress or are hung 
from the upper edges of the basket. Over the basket and 



































































































THE PREMATURE BABY 


37 


covering all but about a fourth of it is placed a blanket, to 
protect the infant from drafts and light. Great care must be 
taken that the hot-water bags do not come in contact with the 
infant, as serious burns may result. Electric pads are some¬ 
times used in place of hot-water bottles. These, however, 
occasionally get out of order, and so must be watched with 
especial care. The room in which the basket is kept should 
have a constant temperature of 75 °. Whether the warm 
room or the heated basket is used, the nurse should take 
the temperature of the child at regular intervals. The aim 
should be to keep this temperature between 98° and ioo°. This 
is difficult to do, and wide variations are sometimes seen until 
things get to running smoothly. If the water bottles are al¬ 
lowed to get cool, the patient’s temperature may fall to 95 0 
or even lower, while, if they are too hot, or placed too close 
to him, they may run the temperature up over 105°. As 
the child will not do well if his temperature fluctuates in this 
way, great care is necessary to keep it within normal limits. 

Prevention of Infection.— The premature infant has very 
little resistance to disease and must be shielded from all possible 
sources of infection. If more than one infant is in a room, 
screens or glass partitions should be used between the cribs. 
All who enter the room should slip a gown over the street 
clothes and if suffering from even the slightest cold should 
wear a gauze mask over the mouth and nose. In the home 
it requires firmness and tact on the part of the nurse to protect 
the child, as there are always grandparents and other fond 
relatives who insist that they just must hold the baby and 
kiss him. One cannot refuse them a glimpse of the infant, 
but one must require that a handkerchief be held over 
the face, that the child be not touched, and that the visit be 
brief. 

Routine Care.— The secret of caring for these delicate 
infants lies in doing the things which are required as quickly 
and with as little disturbance to the patient as possible. For 


38 TEXTBOOK OF PEDIATRICS FOR NURSES 

proper cleanliness it is necessary to change the diaper or pad 
when soiled or wet. The bath is dispensed with, but the child 
is gently rubbed off with olive oil every second day when the 
coverings are changed. The feedings, unless from the breast, 
are given without removing the infant from his bed. The 
position of the child can be changed at each feeding time. 
The temperature at first should be taken every four hours, 
but, as soon as it is satisfactorily regulated, every eight hours 
is enough. Beyond this, the less the patient is handled, the 
better he will do. 

Prognosis. —Without special care and careful feeding with 
breast milk, most of these babies die. If they fall into experi¬ 
enced hands at birth, their chances of living are good if they 
weigh over four pounds. At three pounds, there is a fair 
chance of success; below that the outlook is not good, but still 
some do live and thrive, and one should never give up hope 
of ultimate success. 

The progress of these infants, at best, is never rapid. For 
a long time their weight may remain stationary, then there is 
a gradual gain—perhaps an ounce or two a week. Slowly 
they gain momentum and eventually grow at the same rate as 
other babies. By two years, many of them have caught up 
to their more fortunate fellows, and go through life on an 
equal footing with them. 

Rickets in the Premature Baby. —For some reason, pre¬ 
mature infants are particularly apt to develop rickets. Con¬ 
sequently, measures to prevent this disease should be begun at 
the earliest possible moment. Usually by the time the infant 
is three months old one may start cod-liver oil, giving two 
or three drops after each feeding. If the digestion will per¬ 
mit, this amount is. slowly increased up to fifteen drops three 
times a day. The careful use of ultraviolet rays is also 
recommended for the prevention of rickets in these cases. 


CHAPTER IV 

GENERAL CONSIDERATIONS 
OF FEEDING 





CHAPTER IV 


GENERAL CONSIDERATIONS OF FEEDING 

Importance.— Infant feeding is the most important part of 
pediatrics. When we consider that over half of the deaths of 
babies during the first year are due more or less directly to 
nutritional disturbances, we see what a factor proper feeding 
can be made in reducing infant mortality. It is a subject about 
which every mother and every nurse must know something, 
and the more they know the better. Unfortunately one cannot 
feed babies by rule. There can be no standardized method 
of feeding, because there are no standardized babies. In 
the last analysis, beyond all knowledge of the principles of 
nutrition, infant feeding is an art. In consequence, every 
infant from the time of his birth should have his feedings su¬ 
pervised by a physician skilled in that art. What follows, then, 
is to be taken in the light of underlying principles and proce¬ 
dures,. which—while they may be true for babies as a whole— 
should not be considered as applying to any particular baby. 

Food Elements.— Any diet to be satisfactory must contain 
certain food elements: proteins, fats, carbohydrates, salts and 
water. Each of these has its own part to play in the activity 
and growth of the child. 

Proteins are necessary to replace tissue waste, and also for 
growth. The curd from the milk and the white of egg are 
examples of food proteins. Slightly different proteins are 
found in the milk of different animals. The most digestible, 
from the infant’s standpoint, is that from mother’s milk. 
When proteins are insufficient in the diet, there is anemia 
and slow growth. Infants fed on condensed milk, which is 
low in protein but high in carbohydrate, occasionally get very 

41 


42 TEXTBOOK OF PEDIATRICS FOR NURSES 

fat. This is not desirable, however, as they are soft and flabby, 
and are particularly susceptible to disease. When an excess 
of protein is given, there are large, grayish, crumbly stools, 
constipation and stationary weight. For this reason food 
containing a high amount of protein is given in certain types 
of diarrhea. 

Fats are used by the body to produce heat and energy. They 
are readily stored up in the subcutaneous layers. This is 
particularly true in healthy infants who are generously padded 
with rolls of firm fat. Fats stay in the stomach longer than 
other foods and so are apt to cause vomiting. When much 
fat is taken it may appear in the stools as “soap curds.” 

Carbohydrates are of two sorts: the sugars which are soluble 
in water, and the starches, which are insoluble. The sugars 
are of various kinds: lactose, or milk sugar, which is found 
both in mother’s milk and cow’s milk; cane sugar; and maltose 
and dextrin, which two usually are found together under 
the head of dextrimaltose. These sugars are easily absorbed 
and cause a rapid gain in weight. In excess, however, they 
are apt to cause flatulence and diarrhea. The starches which 
the child gets in the form of cereal gruels are more slowly 
digested. They are not well taken care of by the infant until 
three months of age, and usually are not added to the diet 
before that time. They do not occur in mother’s milk. 

Salts are necessary for growth, particularly of the bones. 
In normal diets they are present in large enough quantities 
to supply the demands of the body, and no special notice of 
them need be taken in preparing the infant’s food. 

Water is one substance which is absolutely essential to life. 
An infant can go several days without food, with no serious 
consequences, but, if deprived of fluids, even for a few hours, 
alarming symptoms develop. A normal infant needs about 
one fifth of his body weight in fluids in each twenty-four hours. 
Thus a 5-lb. baby needs i lb. of fluid or i pt. (A baby of 
2,500 gm. needs 500 c.c. of fluid.) 


GENERAL CONSIDERATIONS OF FEEDING 43 

In addition to these substances which can be weighed and 
measured, there are other important elements in the diet, 
about which our knowledge is unfortunately far from com¬ 
plete. These factors are spoken of as ‘Vitamins.” Of these 
the most important are the antiscorbutic, which is found in 
orange juice and many other fresh foods, and which prevents 
the development of scurvy, and the antirachitic, found in 
mother’s milk and cow’s milk to some extent, and to a high 
degree in cod-liver oil, which protects the child from rickets. 

Furthermore, there are substances in mother’s milk which 
protect the nursing child from certain contagious diseases. 
The child acquires with the milk immunity to diseases to which 
the mother is immune. Thus, if the mother has had measles, 
the child on the breast will not contract the disease, even if 
exposed. This, of course, is a strong argument in favor of 
breast feeding. 

Food Requirements. —The adult needs food to keep up 
his body heat and to supply energy for his various activities; 
he needs nothing for growth. An infant needs much more 
food in proportion to his weight than an adult, because he must 
grow and because loss of heat is in proportion to body sur¬ 
face, not to bulk, and an infant has more surface in propor¬ 
tion to his weight than an adult. In order to know how much 
food an individual is getting, we are accustomed to figure 
the caloric value of his diet. We know, for example, that 1 
gm. of protein furnishes 4 calories, and 1 gm. of carbohydrate 
the same, while an equal amount of fat produces 9 calories. 
Knowing the composition of any food, we can then tell how 
many calories a given amount of it contains. Thus we know 
that 1 oz. of cow’s milk furnishes 20 calories. When we figure 
out the caloric value of the food taken by infants and children 
who are in good health and are gaining well, certain very def¬ 
inite facts become evident. The normal infant at birth requires 
in the neighborhood of 50 calories a day for each pound of 
his body weight (no calories per kilogram). As he grows, 


44 TEXTBOOK OF PEDIATRICS FOR NURSES 

this figure gradually becomes less, so that a year-old baby 
will do well on about 35 calories for each pound (80 calories 
per kilogram). 

Interval Between Feedings. —Regular habits of nursing 
should be insisted upon from the first. When the doctor has 
decided at what times he wishes the patient fed, nothing should 
be allowed to interfere with the schedule. If asleep at feeding 
time, the baby should be awakened. For the night feedings, if 
there is fear of the mother or nurse sleeping through, an alarm 
clock should be used. After a short time this precaution will 
not be necessary—the baby will be the alarm. 

Formerly, babies were fed every time they cried. The fact 
that humanity survived speaks volumes for the hardihood of 
the race. A baby is as apt to cry because his stomach is too 
full as because it is empty, and to give more milk to an infant 
with a full stomach is to bring on an attack of colic, or worse. 
Gradually experience and some experimental work have shown 
that long feeding intervals are better for the baby and easier 
for the mother. The four-hour interval is perhaps the most 
satisfactory. The baby is fed at six, ten, two, six, ten, two, six 
feedings in the twenty-four hours. By the end of the second 
month, the 2 A.M. feeding may usually be omitted, so that 
the baby and mother sleep through from 10 P.M. to 6 A.M. 
The 10 P.M. feeding can usually be dropped by fourteen 
months, while at eighteen months the child does well on three 
meals a day. 

Sometimes it is felt wise to feed somewhat more frequently, 
when a three-hour schedule is adopted during the day, with 
four hours between the night feedings, thus: six-nine-twelve- 
three-six-ten-two. This gives seven feedings in the twenty- 
four hours. 

Methods of Feeding. —There are three methods of infant 
feeding: mother’s milk, mixed feedings and artificial feedings. 
Which of these methods will be used depends upon the amount 
of breast milk available and upon the age of the child. 


CHAPTER V 

MATERNAL NURSING 

















CHAPTER V 


MATERNAL NURSING 

One does not have to be around infants long to recognize 
the immense difference between those fed on the breast and 
those who are artificially fed. No formula has ever been de¬ 
vised which proved half as satisfactory for feeding babies as 
mother’s milk. Fortunately most mothers can nurse their 
babies, and many with a very inadequate flow of milk can be 
helped and encouraged to the point where they can supply 
their infants adequately. It is a mother’s duty to nurse her 
child, and on no consideration should she evade this duty, ex¬ 
cept on the advice of a physician. A sympathetic nurse can do 
much to persuade a doubtful mother that she should suckle her 
own infant. 

In this day and age with its diversified interests, many 
mothers fail as nurses, simply because they do not lead a sensi¬ 
ble sort of life. 

Food. —The diet of the nursing mother should be plain, 
wholesome and abundant. Foods which agree with the mother 
are not apt to make the child ill through her milk. As she is 
eating for two instead of one, she will need more food than 
formerly. It is, however, a mistake to cram a mother with 
food which she does not want in order to increase her milk 
supply. Many a mother has been made ill in this way. If it is 
desired to increase the flow of milk, it can best be done by 
giving liquids, such as cream soups, cocoa, cereal gruels and 
milk. Most mothers can take a quart of milk a day without 
discomfort, and it is the best stimulant for the breasts which 
we have at our disposal. Drugs are useless in increasing the 
supply of milk. 


47 


48 TEXTBOOK OF PEDIATRICS FOR NURSES 

Sleep and Rest. —Practically all nursing mothers find that 
they need more sleep than formerly. They are almost always 
disturbed at least once during the night, and must make up 
this loss. At least eight hours sleep at night with a nap 
or a long rest in the middle of the day is essential. Some 
mothers who are habitually tired from their many duties profit 
by lying down to nurse the baby during the day, instead of 
sitting up. This simple expedient insures at least an hour’s 
extra rest. 

Care of the Bowels. —Young mothers almost always suffer 
from constipation. They should be careful that the bowels move 
well at least once a day. To this end, aromatic fluid extract 
of cascara, compound licorice powder and various other laxa¬ 
tive preparations are useful. Recourse must occasionally 
be had to an enema. The saline cathartics should be avoided, 
as they sometimes upset the infant. 

Exercise and Recreation. —Exercise, particularly out-of- 
doors, should be commenced as soon as the mother is strong 
enough. Only the milder forms which can be undertaken 
without fatigue should be practiced. A two hours’ walk in 
the park or open country or a few holes of golf are excellent. 
She should also have a certain amount of recreation which 
will get her mind off of the baby for a time, such as an 
occasional visit to the theater. On the other hand, many 
women fail as nurses because soon after the baby arrives they 
attempt to go back to the whirl of debutante days. This soon 
ends in a diminished milk supply and an upset baby. In other 
words, the first consideration of the nursing mother must be 
not her own pleasure but the well-being of her baby, and her 
life must be ordered accordingly. 

Mental State of Mother. —The mental and emotional state of 
the mother has a profound effect on the baby. Violent emo¬ 
tion, such as anger or a severe fright, often causes a complete 
cessation of the milk for many hours. Worry and anxiety 
frequently cause a diminished supply. If the mother is happy 


MATERNAL NURSING 


49 


and contented, she is apt to have a good baby. If she is 
irritable and depressed, her baby is more than likely to make 
matters worse by being cross and colicky. It is probable that 
unpleasant emotions liberate substances which pass over in the 
milk and act as poisons to the baby. 

Acute Illness. —Minor ailments, such as colds, tonsillitis, 
gastric upsets and the like, while they may cause a lessened 
supply of milk for a few days are not indications to wean 
the baby. 

Menstruation. —Many mothers have a return of their men¬ 
strual periods while still nursing. This usually causes a slight 
upset on the part of the baby for a few days. Vomiting, and 
a few loose, green stools, are not unusual. A certain amount of 
fretfulness is also the rule. These disturbances usually clear 
up in about three days, however, after which nursing goes on 
normally. 

Care of the Breasts. —The nipples should be carefully washed 
before and after nursing with a saturated solution of boric 
acid. This should be applied with fresh cotton pledgets. If 
the nipples become cracked or sore, they may be treated with 
zinc oxide ointment or tincture of benzoin, 5 per cent in liquid 
petroleum. In either case it is well to use a nipple shield until 
the nipple has had a chance to heal. A cracked nipple is always 
a source of danger as it gives a portal of entry to bacteria, 
which may set up a breast abscess. In consequence, such a 
nipple should always be protected with a sterile gauze pad 
between nursings. 

Technic of Nursing. —Generally only one breast should be 
used at a feeding, alternate breasts being given at successive 
feedings. As a rule, a mother who has not enough milk in 
one breast when so given will not have enough in both breasts, 
if both are given at each feeding. The mother may nurse 
either sitting or lying down. In either case, the baby is sup¬ 
ported on the arm corresponding to the breast to be given, 
while the breast tissue is held away from the baby’s nose with 


50 TEXTBOOK OF PEDIATRICS FOR NURSES 

the fingers of the other hand. The first milk which comes 
flows freely and in the first five minutes the baby receives at 
least 75 per cent of his food. The milk which comes later is 
richer in fat and comes more slowly. At the end of fifteen 
minutes the baby has received practically all that he is going 
to get, and to allow him to nurse longer than twenty minutes 
is simply tiring both mother and infant. At the end of each 
nursing, the baby should be held over the shoulder and gently 
patted on the back for a few minutes before being laid down. 
This allows any air which has been swallowed with the food 
to come up, and frequently prevents colic and vomiting. 

Indications of Insufficient Breast Milk. —The breast-fed 
baby should show an average gain of at least 4 oz. (no gm.) 
a week. When he fails to show such a gain, one should always 
question the quantity of food the baby is receiving a day. 
This can be readily determined by weighing the baby before 
and after each feeding. The difference in weight represents 
the amount of food which the baby has received. In making 
these weighings, it is not necessary to undress the baby and 
no calculation is necessary for the clothes. 

The baby who is not getting enough food is often entirely 
contented; on the other hand, he frequently does his best to 
make his troubles known. He is not ready to stop nursing 
even after he has been at the breast for a long time, and 
when taken from the breast he cries and fusses for some time. 
An hour or two after nursing he begins to cry again, and 
cannot be comforted until his next feeding time. If kept at 
an emptied breast, he may gag, choke and often even vomit. 
He is apt to be constipated, but, when the amount of food 
falls quite low, he may have frequent small stools which 
resemble meconium. They are dark, greenish black and of a 
shiny appearance. 

The treatment of these conditions is either to increase the 
supply of breast milk, or make* up the deficiency with some 
other food, or both. 


MATERNAL NURSING 


5i 


Indications of Excessive Breast Milk Feedings. —Most 
babies who take too much breast milk promptly regurgitate 
the surplus. Some, however, will retain amounts far in ex¬ 
cess of their needs. This is particularly true of babies who 
are fed at frequent intervals. Such babies usually go to sleep 
immediately after nursing, only to awake screaming in fifteen 
or twenty minutes. They clench their fists and draw up their 
legs as though in pain, and usually are not comfortable until 
they have eructated or passed flatus in considerable amounts. 
This condition, commonly called colic, is practically unknown 
except in overfed infants. Babies who' are getting too much 
frequently alternate between constipation and diarrhea, and 
almost invariably vomit as well. The stools are apt to show 
large, whitish curds, which are due to an excess of fat. These 
overfed infants are also particularly susceptible to skin erup¬ 
tions, especially to eczema of the face and scalp. 

The diagnosis is again made by weighing the baby before 
and after nursing. Treatment consists in lengthening the in¬ 
terval between nursings, or shortening the time of nursing, or 
both. It is not uncommon to see babies gaining rapidly on 
breast feedings of only five minutes every four hours. Increas¬ 
ing the amount of outdoor exercise which the mother gets fre¬ 
quently helps when the milk is too rich in fats. 

WET-NURSING 

It sometimes happens that an infant for whom the mother 
has insufficient breast milk does badly on a formula. Fre¬ 
quently the only salvation for such infants lies in milk from 
another nursing mother. Unfortunately, breast milk is diffi¬ 
cult to obtain even in large cities. Some hospitals maintain a 
regular staff of wet nurses recruited from patients in the ma¬ 
ternity clinic, or from homes for unmarried mothers, such as 
the Florence Crittenton Missions. It would be splendid if every 
city could have a Breast Milk Exchange where mothers with an 


52 TEXTBOOK OF PEDIATRICS FOR NURSES 

excess could take their milk, and from which it could be dis¬ 
tributed to delicate infants. But the difficulties in the way of 
such enterprises have made them fail in almost every instance. 

Selection of Wet-nurse— In an emergency, milk from al¬ 
most any nursing mother is better than none. However, if 

there is a choice the 
nurse should be be¬ 
tween eighteen and 
thirty-six years o f 
age, of placid disposi¬ 
tion and cleanly hab¬ 
its. She should, of 
course, be free from 
syphilis and active tu¬ 
berculosis and, if she 
is to come in contact 
with the patient, she 
should also be free 
from gonorrhea. Her 
own infant is the best 
guide to the quality 
of her milk. If he is 
robust, her milk is in 
all probability satis- 

_ __ ^ ^. factory. It is not nec- 

Fig. 7.—Massage of Breast. This wet nurse 
frequently gave a quart of milk a day. She CSSary that her baby 

and P tottle y cor S r°ectly d “ d “ h ° lding be of the Same a S e as 

the patient, provided 
he is over three weeks and under a year of age. Before the 
third week the milk has not yet reached a constant composition 
and still shows some of the characteristics of colostrum, while, 
after a year, the milk is usually of poor quality. 

Method of Obtaining Milk. —It is usually better to feed the 
breast milk from a bottle than to have the wet-nurse suckle the 
patient. In this way one knows exactly how much the 






MATERNAL NURSING 


53 


infant receives without the inconvenience of weighing him 
before and after nursing, and the chance of any infection from 
the nurse is rendered very much less. The milk may be drawn 
with a breast-pump, or better, it may be expressed by hand. 
The hands of the nurse are thoroughly cleansed with soap and 
water, and the nipple and breast with boric acid. A sterile 
graduate or a bottle and funnel is held below the nipple with 
one hand. With the thumb and forefinger of the other hand 
the breast is grasped about an inch from the nipple, and firm, 
rhythmical pressure made with the thumb. This procedure 
forces the milk from the breast into the graduate or bottle. It 
can then be kept on ice until used, or, if wanted at once, it can 
be reheated to body temperature and fed. 

Care of Wet-nurse’s Baby. —If the nurse has sufficient milk 
for both infants there is no difficulty. At each feeding time her 
own infant nurses on one breast after the other has been ex¬ 
pressed for the patient. If she has not enough for both, it 
becomes necessary to put her baby on mixed feedings, giving 
both breast and formula. 

As the success of a wet-nurse depends largely on her being 
free from anxiety, it is necessary that everything be done to 
keep her baby in excellent condition, and to this end the feeding 
of her baby should receive the same careful attention from 
the doctor and nurse as is expended on the feeding of the 
patient. 

The Wet-nurse in the Home. —Great tact is usually necessary 
in handling a wet-nurse in a private home, and one must be 
governed largely by her former status in society in deciding 
whether she shall eat with the servants or shall occupy a place 
midway between them and the family. Besides caring for her 
own infant and supplying milk for the patient, she should have 
duties enough about the house assigned to her to keep her occu¬ 
pied for part of her day. She should, also, be encouraged to 
spend several hours a day out-of-doors. Her food should be 
plain but nourishing, and she should have at least a quart of 


54 TEXTBOOK OF PEDIATRICS FOR NURSES 

milk a day to drink. Her remuneration will depend entirely on 
circumstances, but should be definitely settled in advance. 
Where available, colored wet nurses will usually be found 
easier to get along with than white ones. Their milk is equally 
good and usually more abundant. 

WEANING 

Most of the dread with which mothers look forward to the 
process of weaning from the breast is unfounded. If the baby 
is weaned gradually, and to a satisfactory diet, no difficulty is 
experienced, either by the baby or the mother, except in the 
occasional case. On the other hand, it is a step which should 
never be taken lightly. 

Indications for Weaning. —It is not wise for a mother to 
nurse her baby longer than one year. If nursing is continued 
beyond that time, the milk becomes poor in quality and the baby 
gains slowly and becomes pale and flabby. So it is well to 
begin weaning the baby before the end of the first year. If 
the mother should lose her milk before that time, it is of course 
necessary to wean. Certain diseases also make it imperative 
that a mother wean her baby. Active tuberculosis is an indi¬ 
cation, both for the sake of the mother and the child. Eclamp¬ 
sia is an indication, as in that disease the milk is a poison to 
the baby. Diabetes and the severer grades of nephritis are 
grounds for weaning, as are acute infections such as typhoid 
fever and pneumonia. In the latter it sometimes happens that 
after recovery the mother can again nurse the baby successfully. 
A two-months-old patient of mine was put upon the bottle 
because the mother had influenza and pneumonia. After an 
illness of three weeks, the mother again put the infant to the 
breast at regular intervals; gradually her milk came back and 
she nursed the baby successfully through the ninth month. 

Pregnancy is an indication to wean the baby. But, if the 
nursling is doing well, the weaning may be carried out so 


MATERNAL NURSING 55 

slowly as to run no risk of upsetting either mother or 
child. 

Method of Weaning. —Just how the baby should be weaned 
depends of course on why it is necessary to take the step, but, 
in general, weaning should be carried out slowly. For ex¬ 
ample : A mother with abundant milk, who has nursed her baby 
for nine months, may begin by replacing the 2 P.M. feeding 
with a bottle; after two weeks, she may nurse at 6 A.M., 2 P.M. 
and 10 P.M., giving bottles at 10 A.M. and 6 P.M. After 
another two weeks, the 2 P.M. nursing may also be replaced by 
a bottle. Then the 6 A.M. feeding is replaced, and finally the 10 
P.M. Done in this way, the baby is rarely upset, and the 
mother has little inconvenience from overfilled breasts. This is 
weaning under ideal conditions, but often it is necessary to 
change to the bottle abruptly. The important thing to remem¬ 
ber in that case is to put the child on a formula which is far 
below his calculated needs in strength, and somewhat below in 
amount, increasing to his normal strength gradually as he 
shows he can handle the stronger food. It is far better to have 
an infant lose a little from temporary underfeeding than to 
have him become upset and lose a great deal. The importance 
of beginning with a weak formula when weaning cannot be 
emphasized too strongly. 

The Breasts During Weaning. —It very frequently happens 
that weaning is more upsetting to the mother than to the child. 
The breasts become very full and painful. It is usually a mis¬ 
take to resort to the breast-pump, as this simply postpones the 
day when the body strikes a balance between supply and demand. 
The filling of the breasts can be lessened by decreasing the 
fluids taken by the mother, and by administering saline cathar¬ 
tics, which will still further reduce the fluids in the body. A 
tight binder supporting the breasts and ice-caps applied to them 
are also of assistance. Rarely it is necessary to employ drugs 
to lessen the pain; of these, aspirin and codein are perhaps the 
most valuable. 


56 TEXTBOOK OF PEDIATRICS FOR NURSES 

MIXED BREAST AND ARTIFICIAL FEEDINGS 

Mixed feeding is a compromise between maternal and arti¬ 
ficial feeding. Many mothers who have not enough milk to 
supply their infants completely still have enough to give a little 
at each feeding, or to give two or three complete feedings a 
day, the other feedings being supplied by formula. Weaning, 
as we have seen, is best accomplished by resorting temporarily 
to mixed feedings. There are two methods of employing mixed 
feedings : complementary and supplementary feeding. 

Complementary Feeding. —This consists in giving breast 
and bottle, both, at each feeding. The baby is allowed to nurse 
perhaps ten minutes on the breast, and is then promptly given 
the bottle. Care must be taken that the formula given is not 
too sweet, for in that case the infant will often refuse the 
breast in expectation of receiving the bottle which he prefers. 
For this reason milk sugar is sometimes to be preferred to 
cane sugar during mixed feedings. This method has the ad¬ 
vantage over the following, that it stimulates the breast at each 
feeding, thus tending to increase the supply. 

Supplementary Feeding. —This is the plan outlined in the 
section on Weaning. It consists in substituting a bottle for an 
entire breast feeding. It is particularly useful when it is 
desired to decrease the supply of breast milk. 

Solid Foods in Mixed Feedings. —A great majority of 
mothers who nurse their infants for six months or longer slip 
automatically into a variety of mixed feeding. They give the 
baby cereal, or a crust of bread, or a cracker from time to time 
as he seems hungry. In welfare work among the more ignorant 
mothers it is a good practice to suggest well-cooked cereals and 
broths at the earliest possible date, knowing that if these are 
not given the chances are the child will be offered cakes and 
tea or coffee. Even in cases where one has complete super¬ 
vision of the feedings, it is frequently desirable to give farina 
at one or two breast feedings as early as the seventh month. 


CHAPTER VI 

ARTIFICIAL FEEDINGS 








CHAPTER VI 

ARTIFICIAL FEEDINGS 

There are almost as many methods of artificial feeding as 
there are pediatricians. And each man, knowing his own sys¬ 
tem thoroughly, gets better results with it than he does with 
other methods. But all methods fall short of the ideal, for no 
one has yet devised a formula which is as satisfactory a food 
for infants as mother’s milk. In this chapter these different 
plans of feeding cannot even be touched upon; all that can be 
done is to outline the preparation and administration of the 
foods most used in infant feeding. 

If one cannot have mother’s milk for the infant, and cannot 
procure breast milk from a wet-nurse, then by far the best 
substitute is cow’s milk properly modified. By modification is 
meant the changing of the milk by dilution and addition of 
various substances so that it can be better digested and will 
better nourish the infant. Modification is necessary because 
whole cow’s milk is not well handled by the infant’s digestive 
organs. 

Relative Composition of Woman’s Milk and Cow’s Milk.— 

Both of these milks contain all of the elements necessary for 
the baby, but in different proportions, as is shown in the 
following table: 


Relative Composition of Woman’s Milk and Cow’s Milk 


Food Element 

Woman’s Milk 
Per Cent 

Cow’s Milk 
Per Cent 

Fat . 

3-5 

4 

Carbohydrate . 

7-5 

4-5 

Protein . 

1.25 

3-5 

Salt . 

0.2 

0-75 


59 












6 o TEXTBOOK OF PEDIATRICS FOR NURSES 


A study of this table shows that cow’s milk is richer in every 
ingredient except sugar. In consequence, the first step in prac¬ 
tically all modifications is to dilute the milk and add sugar. Un¬ 
fortunately there are chemical differences which are not shown 
in the table. The protein of cow’s milk, in addition to being 
greater in quantity, is different in nature and has the disad¬ 
vantage of forming large, hard curds in the stomach, where 
mother’s milk forms soft, flaky curds. This can be partially 
remedied by boiling and by various additions to the milk, to be 
discussed later. 

Choice of Cow’s Milk.— Milk for babies should be the best 
obtainable. It should be clean, fresh and from healthy animals. 
It should contain no preservative or adulterant. To obtain 
these ends, it is necessary that the cows be well-kept, frequently 
brushed and washed, that they should be tested with tuberculin, 
and be discarded if suffering from tuberculosis or other com¬ 
municable disease. All utensils used for milk should be kept 
scrupulously clean and frequently scalded. All persons coming 
in contact with the milk should be healthy, and should exercise 
unusual care as to cleanliness. The dairy should have facilities 
for cooling the milk rapidly and keeping it cool. It should be 
delivered within thirty-six hours after milking. 

Milk from mixed herds is preferable. Milk from a single 
cow is not to be recommended as it varies too much from day 
to day, and as the supply is not dependable. 

Frozen Milk. —It sometimes happens that the milk delivered 
in winter is received partially frozen. Such milk when melted 
will frequently show yellow fat droplets floating upon the top. 
These should be removed before preparing the formula. Fro¬ 
zen milk seems to be more difficult to digest, and sometimes 
causes slight intestinal disturbances in delicate infants. Boiling 
the milk lessens its bad effects. 

Sterilization of Milk. —Unless one is absolutely certain as to 
the purity and cleanliness of the milk supply, it is far safer to 
boil it. This should always be insisted upon in welfare work, 


ARTIFICIAL FEEDINGS 


61 


where only the cheaper grades of milk are available. Even 
with good grades of pasteurized milk there are certain advan¬ 
tages to boiling which outweigh the objections. The only 
grave objection to boiling is that it destroys the vitamin which 
protects the child from scurvy. This difficulty can be remedied 
by giving the child each day about i oz. (30 c.c.) of orange 
juice or tomato juice in an equal amount of water. This pre¬ 
caution should never be omitted when using boiled milk. 

Choice of Formula. —While the infant’s feedings should be 
prescribed by the physician, it is difficult to discuss the prepa¬ 
ration of feedings without first giving a general idea of the 
approximate formulas for infants of different ages. These are 
at best only suggestive and should not be interpreted as apply¬ 
ing to any individual infant. 

In practice one does not as a rule figure the formula as 
closely as is done in this table. It is usually wise to make some 
allowance for spillage or other accident. In hospitals, where 
numbers of formulas are to be made up, it is customary to 
have some simplified method of expressing the proportions 
that are to go into the mixture. A very convenient system, for 
example, which is used in some hospitals, is to express all 
feedings in terms of 20-oz. mixture. A baby who is to receive 
five feedings of 6 oz. each, 18 oz. of milk, 1^2 oz. of sugar, 
made up to 30 oz. of water, would have his formula written 
30 oz. of a 12 in 20 mixture with 1 oz. of sugar added, given 
in five feedings. In this way all 12 in 20 mixtures may be 
made up together and much time and material saved. 

Equipment Necessary for Milk Modification. —In an emer¬ 
gency all that is needed to prepare the baby’s milk is a nursing 
bottle and a sauce-pan. But where there are bottles to be pre¬ 
pared each day the work is made far easier by having certain 
utensils adapted to the purpose. The following list may be 
varied to suit the conditions: 

Two quart double-boiler 

Measuring glass graduated in ounces 


62 


TEXTBOOK OF PEDIATRICS FOR NURSES 


in 

< 

>-} 

t) 

S 


< 

H 


8 

8 

O 


(Additional Foods 

Orange Juice 

Cereal 

Broth 

Green vegetables 

added to broth 

Total 

Volume 

ooi—iTj-uoomooo o 

rj- 

Diluent 

Water 

U 

Cereal water 

U U 

U (( 

<c u 

Ounces 

of 

Sugar 

L 

I Ya 

I Va 

I 

y* 

0 

Ounces 

of 

Milk 

oo o ^ rj- oo rt- oo o oj 

mmi-hh-iNNOIco c<0 

Ounces 

per 

Feeding 

CO co Tf lOVO Ixoo 00 00 00 

Number 

of 

Feedings 

'O'O'OuoLoiouomm io 

Weight 

in 

Pounds 

tx00 ON O i—i co ^t-vo 00 O 

Age 

rth. 

month . 

months . 

months . 

months . 

months . 

months . 

months . 

months . 

year. 




CO Tt- lOVO 00 


O HI 

























In Metric System 


ARTIFICIAL FEEDINGS 


63 


in 

13 

o 

o 


aj 

G 

O 


13 

13 

< 


<u 

*3 


0 

b/D 

G 

”3 J3 

<U 4-> 

aj 

i— O 

u 

0 s-, 

O 

U CQ 


crt 

aj O 

4-> Uh 

<U .Q 

b/D 

O o 

> -!-> 


13 

<v 

13 

13 


Total 
Volume 
in Cubic 
Centi¬ 
meters 

OOOOVOOvovovo VO 

VO 0 'O IT! N 0 01 01 01 01 

TfVOtNtN»COO>HMI-l h-l 

HH hH hH hH hH 

Diluent 

u 

<v 

4_J V« v« >« \« 

Oj ~ ~ "* "* 

£ 

a; "3 

aS - - - J-i ~ 2 S 3 C 

^ <U 

> U 

Grams 

of 

Sugar 

VO vo 10 iO vo vn vo 10 VO O 

01 CD 01 CO CO CO CO 01 m 

Cubic 

Centi¬ 

meters 

of 

Milk 

OvoOOOO'-O^OO 0 

O fx vo O O O i\ MO 0 

01 0) CO i- ICO O K00 Os 

Cubic 

Centi¬ 

meters 

per 

Feeding 

vo O vo O vo O vo vo 10 vo 

NOOliOKONOIPl 01 

HHHHOI01010I 01 

Number 

of 

Feedings 

VO'O'O vovovovovovo vo 

Weight 

in 

Kilos 

vo vo vo 

co CO tJ* -F 10 V0\0 lx CO Os 


<u 

b/D 

< 


co co co co c/^ c/5 co 

.(_> -t-J -4-t +J +-> 4-1 4-> 

CCGGGGGG 

OOOOOOOO 

ESSScsES 


aj 

<L> 


PQ 


W 01 co it- vo VO CO o 





























64 TEXTBOOK OF PEDIATRICS FOR NURSES 

Funnel for filling bottle 
Nursing bottles 
Wire rack for bottles 
Bottle brush 

Scales to weigh carbohydrates 

The bottles may be had in various sizes but should be of a 
type with a gradual taper toward a large neck so that they may 
be easily cleaned. Or the cylindrical Hygiea bottles may be 
used. The bottles should be thoroughly cleaned and boiled 
before filling. After using they should be rinsed out with cold 
water. 

The nipples should be thoroughly cleaned and boiled when 
purchased. After using, they should be scrubbed inside and out 
with soap and water, boiled and kept in a sterile glass jar until 
used. The hole in the nipple should be such that when the bottle 
is inverted the contents will just drip through. If the hole is 
too small, it may be enlarged with a red-hot needle; if too large 
the nipple may be put away and used later when the baby is 
taking a thicker type of food. If a nipple has softened to the 
point where it collapses too readily, its usefulness may be some¬ 
what prolonged by stretching a boiled, cotton thread across the 
neck of the bottle and applying the nipple over this. 

If scales are not available on which to weigh the sugar, one 
may have the given amount weighed at the druggist’s, and note 
its volume in the measuring glass. It will be found that the 
table on page 65 roughly represents the volume of the more 
commonly used sugars and cereals. 

These equivalents are convenient in welfare work where 
proper facilities for the preparation of formulas are not avail¬ 
able, but, where possible, formulas should be accurately weighed 
and measured. 

Preparation of Formulas. —In the home it is usually found 
most convenient to prepare the bottles for the day between the 
first and the second morning feedings, starting in time so that 
they may be finished before time for the baby’s bath. The re- 


ARTIFICIAL FEEDINGS 65 

Volume of Sugars and Cereals 


Weight in Ounces 


Food 

Weight in 
Ounces 

Volume in Level 
Tablespoonfuls 

Cane sugar . 

1 

2 

Lactose . 

1 

3 

Dextrimaltose . 

1 

4 

Farina . 

1 

2^ 

Barley flour. 

1 

2^ 

Oatmeal . 

1 

4 


Weight 

in Grams 


Food 

Weight in 
Grams 

Volume in Level 
Tablespoonfuls 

Cane sugar . 

14 

Q 

1 

Lactose . 

1 

Dextrimaltose . 

7 

1 

Farina . 

12 

1 

Barley flour. 

12 

1 

Oatmeal . 

7 

1 




quired amount of milk is poured into the measuring glass, to 
this is added the sugar, the volume being then made up to the 
given total with the diluent, either cereal water or plain, boiled 
water. These ingredients are thoroughly mixed, poured into 
the double-boiler and allowed to boil for five minutes. In the 
meantime the bottles and funnel are boiling in another pan. 
When the milk is ready, the bottles are placed in the rack and 
the amount to be used at each feeding is poured into each bottle 
by means of a funnel. The bottles are then stoppered with 
sterile, absorbent cotton. The rack containing the bottles is 
then placed in a pan of hot water (the water in which the bottles 
were boiled will serve). This pan is then placed so that cold 
water will run into it, slowly at first, and then rapidly. When 
the milk is reasonably cool, the bottles—still in the rack—are 
placed on the ice, where they are kept until ready to use. 


























66 TEXTBOOK OF PEDIATRICS FOR NURSES 



In hospitals, where there is the proper machinery for pas¬ 
teurizing formulas, the routine is somewhat different. After 
mixing the formula, the required amount is placed in each 
bottle, the bottles are stoppered and placed in the pasteurizer, 

where they are kept at 
140° for fifteen minutes. 
The bottles are then rap¬ 
idly cooled and kept on 
ice. 

When feeding time 
comes, one bottle is re¬ 
moved from the ice and 
the milk brought to body 
temperature. This may 
be done by placing the 
bottle in a small saucepan 
of water and heating on 
the stove or alcohol lamp. 
Rather more convenient, 
however, is the electrical 
bottle-heater which is on 
the market. This may be 
kept in the nursery, and 
heats the bottle in a few 
moments. When heated, 
the stopper is removed, 
the nipple applied and the 
feeding is ready to be 
given. In placing the nipple on the bottle, the hands must 
be scrupulously clean, and only the lower part of the nipple 
which surrounds the neck of the bottle should be touched. 

Method of Giving Bottle. —The child may be fed either lying 
in his crib or in the nurse’s arms. In either event the bottle 
should always be held by the nurse—never left propped up in 
the crib. It should be so held that the neck of the bottle is con- 


Fig. 8 . —Bottle Feeding. The baby is held 
in a comfortable position and the bottle 
tilted so as to keep the nipple filled with 
milk. 




ARTIFICIAL FEEDINGS 


67 

stantly filled with milk; this lessens the chance of the child 
swallowing air with his food. If the baby is inclined to gulp 
down his food too rapidly, he should be given a rest from time 
to time by taking the nipple from his mouth. On the other 
hand, if the child nurses indifferently, it is not wise to let him 
have the bottle for more than twenty minutes. When a bottle 
is emptied, it should be promptly taken away from the child, 
so that he may not suck air through the nipple. Any part of a 
feeding which is left by the child should be thrown out, first 
noting how much has been taken. 

FOODS USED FOR INFANTS 

Barley Water. —When the infant is three or four months old, 
it is customary to use barley water as a diluent for the milk, 
instead of plain, boiled water. As has already been pointed 
out, starches as a rule are not digested well before this time. 
The advantages of cereal water in the formula are several. 
The milk forms smaller curds than when plain water is used, 
the caloric value of the mixture is slightly increased, the child 
is apt to be better satisfied and to remain contented longer, as 
the cereal leaves the stomach more slowly, and finally the diges¬ 
tive organs of the child are educated to digest starches, so that 
later he may be given cereals to eat. 

Barley water may be prepared from pearl barley or from 
barley flour. In either case, 1 tablespoonful of the barley and a 
pinch of salt are added to 1 quart of water and boiled down to 
1 pint, in a double-boiler, adding water if the amount de¬ 
creases too fast; the process should take two hours. When 
done it should be strained through cheesecloth. If not used at 
once, it may be kept on ice. Thick barley water is made in the 
same way, except that twice the amount of barley is used. 

Rice Water and Oatmeal Water. —These are made just as 
barley water is, with the exception that the oatmeal water can¬ 
not be strained through cheesecloth. One must use a coarse 


68 TEXTBOOK OF PEDIATRICS FOR NURSES 


sieve. Oatmeal water is considerably more laxative than the 
others, and is of value when an infant is inclined to be con¬ 
stipated. 

Protein Milk. —To i qt. of raw, sweet milk warmed to ioo° 
F., 4 teaspoonfuls of liquid rennet, or i junket tablet, is added. 
This mixture is then kept at room temperature until it has 
firmly “set” into junket. This junket is cut into small cubes and 
the mass poured into a cheesecloth bag and hung in a cool 
place where it is allowed to drain for two hours. The whey 
which drains off is discarded. The curd is pressed through a 
sieve and one layer of cheesecloth by means of a potato-masher, 
from time to time adding boiled water until a pint has been 
added. To this curd suspended in i pt. of water is added i pt. 
of buttermilk. The resulting mixture is protein milk. It has a 
caloric value of 13 per ounce. Saccharin, 1 gr. to the quart, 
may be added to make the mixture more palatable. In warming 
protein milk before giving it to the baby, care must be taken not 
to heat it much above body temperature, as greater heat hardens 
the curd. A nipple with a large hole is essential as the milk is 
much more bulky than most formulas. 

There are on the market several dried preparations, which, 
when mixed with water, skimmed milk or buttermilk, make a 
fairly satisfactory protein milk. 

Protein milk is much used in the treatment of intestinal 
diseases, particularly diarrhea and chronic intestinal indigestion. 
As these conditions improve, the formula is often strengthened 
by the addition of a carbohydrate, of which dextrimaltose is 
best suited to the purpose. 

Reenforced Protein Milk. —This is made exactly like pro¬ 
tein milk except that no water is used, its place being taken by 
buttermilk. Thus the composition is : curd from 1 qt. of milk, 1 
qt. of buttermilk. This mixture is more concentrated and has a 
higher caloric value than protein milk. It is of value in some 
cases of vomiting and diarrhea. 

Dried Junket. —Dried junket or curd is often taken readily by 


ARTIFICIAL FEEDINGS 


69 

a child who will not take the same curd mixed with water and 
buttermilk. It is made by draining the whey from junket, as is 
done in making protein milk, and is fed with a spoon as one 
would a cereal. 

Buttermilk. —Many dairies now supply buttermilk with 
known percentages of fat for use in infant feeding. If none 
such is available, it may be made at home. To a quart of milk 
is added a culture of lactic acid bacilli, and the mixture is in¬ 
cubated at from 80 to ioo° F. until the protein is coagulated 
(twelve to twenty-four hours). It is then churned or beaten 
with an egg beater until smooth, and strained through a fine, 
wire sieve. The fat content can be varied by using whole milk 
or skimmed milk as desired. 

Dried Milk Powders. —During the last few years there have 
come into quite general use a number of brands of dried milk. 
These have been extensively advocated for infant feeding. 
While they by no means take the place of good dairy milk, they 
fill a real need in supplying a food where good, fresh milk is 
not available, especially when traveling. One tablespoonful 
of powder added to an ounce of boiled water makes a mixture 
equivalent to undiluted, partially skimmed milk. 

Condensed Milk. —This is still widely used in infant feeding. 
With increased knowledge of the preparation of formulas from 
fresh, whole milk its use will become less. The advent of 
dried milk removes the only valid argument in favor of con¬ 
densed milk, which was its convenience when traveling. 

Proprietary Baby Foods. —These foods, of which there are 
many on the market, should never be used without a very clear 
understanding of their limitations. None of them is a complete 
food. The dextrimaltose foods are sometimes valuable in 
modifying cow’s milk, replacing, in these cases, the cane sugar 
or lactose. 

Farina. —Two tablespoonsful of farina or cream of wheat 
and a pinch of salt are sprinkled into 10 oz. of boiling milk. 
This mixture is stirred until thick and smooth, and then al- 


70 TEXTBOOK OF PEDIATRICS FOR NURSES 

lowed to cook for two hours in a double-boiler. It is fed with a 
spoon, usually with some milk from the bottle poured over it. 

Beef Broth. —One pound of lean beef is chopped fine, taking 
care to remove all gristle. It is covered with i pt. of cold water 
and allowed to stand for an hour. It is then placed in a double¬ 
boiler, brought to 167° F. and kept at this temperature for an 
hour. Strain through a coarse, wire strainer, pressing as much 
of the juice from the meat as possible. All fat is then skimmed 
from the broth. Add enough salt to season. 

Vegetable and Beef Broth. —Make beef broth as above, and 
to it add as many of the following vegetables as are available: 
peas, string beans, carrots, 2 tablespoonfuls each, spinach p2 
cup. Let simmer for an hour, and strain. 


CHAPTER VII 

DIETS FOR OLDER CHILDREN 



















































































































♦ • 




































CHAPTER VII 


DIETS FOR OLDER CHILDREN 

In outlining diets for children after the bottle days are over, 
the same difficulties are met with as were encountered with the 
sucklings. Children vary and their food must vary. The diets 
set down here are ones which have been found satisfactory in 
the great majority of a large number of normal children. They 
are meant to be suggestive—nothing more. 

Diet for a Child from ten to fourteen months of age 

6 A.M. Whole milk, 8 oz. 

9 A.M. Orange juice, 2 oz., or occasionally prune juice, 
if there is a tendency to constipation, 
io A.M. Cereal, 2 tablespoonfuls with a little milk, but no 
sugar. Well-cooked farina, cream of wheat, oatmeal, 
wheatena and cream of barley are among the best. (Do 
not give uncooked cereal.) 

Milk, 6 oz. 

Toast or zwieback, if still hungry. 

2 P.M. Broth from chicken, mutton or beef. 

Green vegetable—spinach, carrots, asparagus tips, young 
string beans. 

Milk, 4 oz. 

Toast or zwieback. 

6 P.M. Cereal as above. 

Milk, 6 oz. 

Apple sauce, baked apple, pulp of stewed prunes. 

Toast or zwieback. 

io P.M. Milk, 8 oz. (may be omitted any time after I yr.). 

73 


74 TEXTBOOK OF PEDIATRICS FOR NURSES 

Diet for a Child from fourteen months to two years 

6 A.M. Milk, 8 oz. 

8 A.M. Orange juice, apple sauce, baked apple or pulp of 
prunes. 

Cereal, as in the preceding diet. 

Bacon, i slice, well-crisped. 

Milk, 6 oz. 

Toast or zwieback 
i P.M. Broth, 4 oz. 

Egg, soft-boiled or poached, 
or scraped beef, 
or white meat of chicken. 

White vegetable—potato or rice 

Green vegetable—spinach, carrots, asparagus, young peas 
or string beans, stewed celery. 

Milk, 4 oz. 

Toast. 

6 P.M. Cereal 
Milk, 8 oz. 

Stewed fruit, as above. 

Toast or zwieback. 

Many children by the time they are eighteen months do very 
well on three meals a day, in which case the 6 A.M. feeding is 
discontinued, and the other meals given at 7 A.M., 12 130 P.M. 
and 6 P.M. In this case 8 oz. of milk are given at each 
feeding. 

Diet for a Child from two to four years of age 

Three meals are given, arranged about as follows: 
Breakfast: Cereal, milk, egg and bacon, bread. 

Dinner: Broth, meat, white vegetable, green vegetable, milk 
or cocoa, bread, dessert. 

Supper : Cereal or milk toast, milk, stewed fruit, if not given 
at dinner. 

This schedule may be filled in from the following: 


DIETS FOR OLDER CHILDREN 75 

Milk: Maximum amount 0/2 pt. a day, including that used 
on cereal, etc. 

If not perfectly sure of the milk supply, it should be boiled. 

Cocoa: Made with milk may be substituted once a day for 
milk. 

Cereal: Never give uncooked, ready-to-serve cereals. Fa¬ 
rina, cream of wheat, wheatena, cream of barley, oatmeal, 
etc., may be used. They should be cooked at least two 
hours (but are best when cooked overnight) in a double- 
boiler. They should be served with milk or thin cream, 
but with little—if any—sugar. 

Bread: Dry bread, at least three days old, toast, zwieback. 
Avoid hot rolls, hot bread and fancy breads of all kinds. 

Meats: Beef, lamb, lamb chops, chicken. Should be broiled 
or boiled or roasted, and served finely divided. Bacon 
should be fried until crisp. 

Eggs: Soft-boiled, coddled, poached, scrambled or omelet. 

Soup : Light soups with green vegetables, cooked three hours 
or thick soups well-strained. 

Vegetables : Potatoes, baked, mashed or creamed (avoid use 
of new potatoes). Rice, thoroughly boiled. Macaroni 
or spaghetti may occasionally be substituted for potato or 
rice. Spinach, carrots, asparagus tips, string beans, young 
green peas, celery, cauliflower—cooked until tender, 
strained through a colander and served in their own juices, 
with a little salt. 

Fruits: Orange juice, baked apple, apple sauce, stewed 
prunes. 

Desserts: Junket, custard, fruit gelatin, vanilla ice cream. 

Omit tea, coffee, soda water, cake, candy, pastry, salads, 
tomatoes, corn, cucumbers, melons and other articles of food 
not mentioned in the above list. 

To some this diet may seem too strict, and it must not be 
taken too literally. Certainly most four-year-olds are not 
hurt by an occasional piece of candy or simple cake. On the 


76 TEXTBOOK OF PEDIATRICS FOR NURSES 

other hand, they are not benefited thereby and may develop 
the candy habit, which is hard to overcome. 

A few general rules which I have found valuable in feed¬ 
ing children may not be amiss here: 

1. Do not urge the child to eat. This is the most important 
rule, observance of which will avoid many an upset. 

2. Do not make substitutions in his diet to please him. 

3. Do not feed him between meals, even if he has refused the 
the preceding meal. 

4. Do not feed him candy or cake. 

5. Do not feed him raw fruits, except orange juice. 

6. Do not feed him tea, coffee or soda water. 

7. Do not feed him pork products, except bacon. 

8. Do not feed him fried foods. 

9. Do not feed him uncooked cereals. 

10. Do not give him ice water, but offer him good cool water 
frequently. 

Appetite is the only tonic for children, and fresh air is the 
best producer of appetite. 


CHAPTER VIII 
DIAGNOSTIC METHODS 

















CHAPTER VIII 


DIAGNOSTIC METHODS 

In order to treat any child intelligently, the physician must 
first know what is the matter with the patient. And it is right 
here that pediatrics presents unusual difficulties, for—unlike the 
adult—the child cannot, as a rule, describe his symptoms in a 
way to be of any assistance in the diagnosis. The history of 
the case is of value, but more than anything else the physician 
must depend upon his own observation of the child, and upon 
the observation of the parents or nurse who are in attendance 
over a longer time than he can possibly be. In consequence, a 
nurse who observes a child intelligently, and who knows what 
to look for, can be of the greatest assistance to the physician in 
arriving at a proper diagnosis. Furthermore, the nurse— 
particularly if she has been with the child long enough to gain 
his confidence'—can be of great service in smoothing the way 
during an examination. 

Taking the Temperature. —In all children up to six or eight 
years of age, and in sick or nervous children above that age, 
the safest and most accurate method of taking the temperature 
is by rectum. For this purpose a clinical thermometer, having 
a large rounded end, is used so as to lessen the chance of 
injury. Also, the thermometer is usually distinctively colored 
so that there can be no possibility of confusing it with others 
which are used in the mouth. In taking the temperature, the 
bulb of the thermometer is well lubricated with vaselin and is 
inserted for about one and a half inches into the rectum. The 
ordinary “one minute” thermometer should be left in place 
for three minutes. As the rectal temperature runs about a 
degree higher than that taken by mouth, the nurse should al- 

79 


8o TEXTBOOK OF PEDIATRICS FOR NURSES 

ways specify how any given temperature was obtained. Tem¬ 
peratures taken in the groin or axilla are so untrustworthy that 
they should be discarded. 

Counting the Pulse. —The child’s pulse may be taken at the 
wrist or in front of the ear. The quality* as well as the rate, 

should be noticed as 
it is more easily ob¬ 
served and is of equal 
importance. As the 
pulse rate increases 
with exertion or ex¬ 
citement, it is wise to 
take the pulse while 
the child is asleep, if 
possible. The rate in 
disease is sometimes 
so much increased as 
to make accurate 
counts impossible; it 
is seldom that one 
can be certain of a 
pulse which is run¬ 
ning more than 180 
per minute, as it fre¬ 
quently does—for ex¬ 
ample in pneumonia. 
In premature babies 
it is often impossible to count the pulse without a stethoscope, 
in which case it is counted by placing the instrument over the 
apex of the heart. 

Counting the Respirations. —Sometimes a child’s respira¬ 
tions may be counted just as an adult’s—by holding the 
watch in line between the eyes and the chest and watching 
the inspirations. Often, however, it is necessary to place a 
hand upon the chest—to feel it rise and fall, at the same 





DIAGNOSTIC METHODS 


81 



time keeping the eyes on the watch. Here again excitement 
increases the rate, so it is important that the observation be 
made with the child at rest or asleep. 

Weighing the Child. 

—This is as important a 
part of examination as 
taking the temperature, 
and with infants and 
young children should 
not be omitted. The in¬ 
fant scales usually 
fbund on the market, 
which work with a 
spring and on which the 
weight is shown by 
needle and dial, are so 
difficult to use and so 
inaccurate that they 
should be discarded in 
favor of balance scales. 

Scales such as grocers 
use, graduated to quart¬ 
er ounces or to ten 
grams, and provided 
with a large scoop in 
in which the infant may 
be laid, are ideal. For 
older children, a plat¬ 
form scale is indicated. 

Weights should be made stripped or, if any covering is used 
for the baby, this covering should be carefully weighed and this 
figure subtracted from the total weight. 

Holding a Child for Examination. —Many children object 
very strenuously to having the mouth and throat examined and 
this procedure can be very much simplified by the nurse if she 


Fig. io.—Baby Held for Examination of 
Throat. Both wrists are securely held 
in the left hand, while the head is drawn 
back with the right. 




82 TEXTBOOK OF PEDIATRICS FOR NURSES 

holds the child properly. Whether the child be on her lap or 
on the examining table, the method is the same. The child’s 
back is held firmly against the nurse’s chest. The nurse then 
slips her left arm over the child’s left shoulder, holding both 
of the child’s wrists in her left hand. Her right hand is then 
placed upon the child’s forehead, and the head drawn back 
against her right shoulder. When so held, the child finds 
resistance useless and usually acquiesces without further ado. 

Wrapping a Child for Examination. —When it becomes 
necessary to hold a child securely over a prolonged period, as 
when examining the ears or eyes, it is often necessary to wrap 



Fig. ii.—Patient Wrapped for Examination or Treatment. 


him. The patient is placed upon a small blanket, reaching from 
his head to his feet. The legs should be straightened out with 
feet together; the arms should be close to the sides. If the 
nurse stands on the right side of the patient, the edge of the 
blanket nearest her is then passed over the child and tucked 
snugly under his left side—from axilla to feet. This pins the 
right arm firmly to the body but leaves the left arm free. The 
far edge of the blanket is then brought over the child, confining 
the left arm to the side, and is securely pinned with three safety 
pins. The child is thus trussed up in such a way that he can 
move neither arms nor legs, and the examination may proceed. 

Method of Collecting Urine. —In children too young or too 
ill to use a bed-pan or chamber, some special method must be 





DIAGNOSTIC METHODS 


83 

employed for collecting urine specimens for examination. 
With boys, a test tube may be held in place over the penis with 
adhesive straps. With girls, enough urine for examination can 
usually be obtained by means of a small cup made of rubber 
sheeting and lightly filled with absorbent cotton, held in place 
over the vulva by the diaper. When specimens for bacterio¬ 
logical examination are needed, the child must be catheterized. 

Method of Collecting Stools. —Usually the stool as caught 
by the diaper is satisfactory for laboratory examination. In 
cases of diarrhea, and in difficult feeding cases, the soiled 
napkins should be saved in a tightly closed receptacle for exami¬ 
nation by the physician. 

Vaginal Examination. —Girls and girl babies should never 
be admitted to a ward without a vaginal examination, which 
must include a smear for microscopic examination. The nurse 
prepares the patient as follows: the necessary clothing is re¬ 
moved and the patient placed upon her back with heels drawn 
up close to the buttocks and knees widely separated. The legs 
and abdomen are then covered with large towels or sheets. The 
nurse then dons rubber gloves. With the thumb and forefinger 
of the left hand, she holds the labia apart. A bichlorid solution 
1 :10,000 on cotton pledgets is then used to cleanse the parts, al¬ 
ways stroking toward the rectum, and using a fresh pledget for 
each stroke. Three pledgets should be used. The nurse contin¬ 
ues to hold the labia apart while the physician makes the exami¬ 
nation and the necessary smears. The smears may be made by 
means of sterile toothpick swabs, which are introduced into the 
vagina and then rubbed gently on slides. Perhaps the dropper 
method is better. A few drops of 1 :10,000 bichlorid solution 
are taken up in a sterile dropper. These are gently forced into 
the vagina and drawn again into the dropper. This is repeated 
several times, and the fluid thus obtained is dropped on to a slide 
and allowed to dry. In suspicious cases, smears made on at least 
two successive days should be negative for gonococci before 
the patient is released from isolation. 


84 TEXTBOOK OF PEDIATRICS FOR NURSES 

Observations on the Part of the Nurse. —The success of a 
nurse in pediatrics depends on three things: the way she 
carries out the routine care of the child; the degree to which she 
can aid the physician in various diagnostic and therapeutic 
procedures; and finally the keenness and accuracy of her obser¬ 
vation of the child. This last requirement is the most difficult 
to acquire, and comes only after some time spent in caring for 
children. 

Routine Observations. —Certain things must be noted by 
the nurse in practically all cases, and generally they are made 
compulsory by the necessity of filling out charts and records. 
These are temperature, pulse, respirations, stools, urination and 
vomiting. In addition, one can scarcely help noting whether 
the infant is sleeping or wakeful, crying, fretful or contented, 
whether or not he is coughing and whether he is hungry or 
refuses his food. These things even a beginner with children 
will notice. 

General Well-being of Patient .—It requires very much more 
experience to be able to tell whether a child is better or worse, 
to know when there has been a change which should be brought 
to the attention of the physician, and to sense those situations 
which sometimes arise in which immediate action must be 
taken. Practice will enable the nurse to interpret the meaning 
of the color of the child, the rosy tint of health, the waxen 
pallor of anemia, the dull lead-gray of prolonged diarrhea and 
the bluish tint of respiratory failure. She will learn to distin¬ 
guish the firm, elastic tissues of the normal child, the boggy, 
water-filled tissues in edema, and the dry, powdery, inelastic 
skin which shows rapid loss of weight. 

Changes in Condition .—In addition to noting the general 
condition of the patient, the nurse must be quick to appreciate 
changes in his condition. She must recognize increased pros¬ 
tration or restlessness. She must realize at once that a child 
with pneumonia who becomes pale and cold is in danger. She 
should be on the lookout for discomfort due to a gas- 


DIAGNOSTIC METHODS 85 

filled intestine, and must be watchful for distention of the 
bladder. 

Eruptions .—Any breaking-out on a child’s skin may be of 
importance, and when such develops it should be called to the 
attention of the physician at once. When a rash is seen, there 
are certain things which must be noted. One should determine 
its distribution—on what parts of the body it is found. The 
character of the separate spots—whether level with the skin, 
raised, filled with serum or pus—their size and number should 
be noted. One can also decide from the action of the child 
whether or not the eruption itches or is painful. 

Parasites .—In institutional and welfare work, the nurse 
should always be on the lookout for parasites in the hair or 
clothing. This vigilance is for her own protection as well as 
for the good of the patient and those who associate with the 
patient. The most common of these parasites is the Pediculus 
capitis or head louse, which inhabits the heads of a large pro¬ 
portion of children, particularly the girls, who come to free 
dispensaries. Their presence can be detected, even when they 
are not seen themselves, by noting the nits or eggs. These are 
minute, pearlike bodies, so tightly glued to the hairs that they 
do not slip along them as do flakes of dandruff. A search for 
nits should be made on every child admitted to a hospital and, 
if they are found, treatment should be started at once to eradi¬ 
cate them and the child should be isolated until free from 
both parasites and eggs. 

























































































































































































































































































CHAPTER IX 


THERAPEUTICS OF INFANCY 
AND CHILDHOOD 











CHAPTER IX 


THERAPEUTICS OF INFANCY AN;D CHILDHOOD 

Drugs play a very small part in the treatment of children. 
There are but few diseases which can be cured by medicines 
and not many more in which medicines are of real value in 
meeting unfavorable symptoms. This does not mean, how¬ 
ever, that our hands are tied and we must leave all to nature. 
Far from it! Nowhere is the response of the patient to proper 
treatment as rapid and as gratifying as with children. And 
the first requisite of this treatment is good nursing care—either 
on the part of the mother or the nurse. 

This chapter will deal with those methods of treatment which 
are in general use or of particular value, and whose use is 
not specially limited to any one condition. Methods of treat¬ 
ment which are of use in practically only one disease, such as 
intubation in laryngeal diphtheria, will be taken up in dealing 
with those conditions. 

Mustard Pack. —One ounce of powdered mustard is dis¬ 
solved in a little cold water and added to I gallon of water at 
io8° F. A sheet is wrung out of this mixture and wrapped 
about the nude infant, who is laid on a bed protected with rubber 
sheeting. The patient is then covered with blankets and an ice¬ 
cap or cold compress placed on the head. The child is left in 
the pack for from ten to fifteen minutes. At end of that time 
he should be wrapped in warmed blankets. This is an ex¬ 
tremely valuable emergency measure in case of convulsions. 

Mustard Plaster. —One part of mustard is mixed with six 
parts of flour, moistened and spread between pieces of muslin 
the size desired. Before applying, rub the skin with vaselin. 
Leave on until the skin is pink. If carefully used, it may be 

89 


go TEXTBOOK OF PEDIATRICS FOR NURSES 

repeated several times a day. It is much used in bronchitis 
and pneumonia. 

Enemas.— Many sorts of enemas are in use for various pur¬ 
poses. Their administration is made much simpler if one has 
the proper equipment. This consists of an enema bag, an 
adjustable pole on which to hang the bag, a small hard-rubber 
nozzle or small catheter, a fairly firm pillow, extra rubber and 
sheet, diapers and bed-pan. The bedcovers are turned down 
and the child laid upon the pillow, which together with the bed is 
covered with rubber and sheet. The child’s buttocks are 
placed upon the bed-pan, the edges of which are covered with 
diapers. After all the air has been expelled from the tubing, 
the nozzle or catheter, is lubricated with glycerin or vaselin 
and inserted well into the rectum. The desired amount of 
fluid is then allowed to run in, and the nozzle removed. The 
expulsion of the fluid may sometimes be aided by very gentle 
massage of the abdomen. 

The most frequently used enemas are: 

Soapsuds y made by dissolving Castile or other bland soap in 
water at ioo° F. From 4 oz. to a quart are used, depending 
upon the size of the child. 

Water and glycerin, used where an immediate action is de¬ 
sired, particularly when the child has shown a tendency to retain 
the soapsuds enema. Equal parts of water and glycerin are 
used. 

Mineral oil, used when the feces are particularly hard. 

For small infants sufficient fluid can often be given with an 
all-rubber ear syringe, in which case the more complicated 
enema apparatus is dispensed with. Such a syringe may also 
be used in administering drugs by rectum—notably chloral— 
which is sometimes thus given for convulsions, and quinin. 

Rectal Irrigation. —Salt solution at a temperature of ioo° F. 
is used. The patient is placed on his back in bed, with hips sup¬ 
ported by a pillow (this and the bed must be well protected with 
rubber sheeting). The solution is introduced into the rectum 


INFANCY AND CHILDHOOD THERAPEUTICS 91 

from the enema bag by means of rubber tubing and a two- 
way rectal tube, or two catheters—-a smaller for inflow and a 
larger for return—may be used. Outlet tube is shut off until 
about 6 oz. of fluid has been given, when it is allowed to 
drain off into the bed-pan. This process is repeated until fluid 
returns clear. This usually takes about a gallon of salt solu¬ 
tion. This procedure is frequently employed where a thorough 
cleansing of the colon is desired. 

METHODS OF ADMINISTERING FLUIDS 

There are many diseases of infancy in which the condition of 
the patient may become exceedingly grave simply from loss of 
fluids from the body. This is particularly true in cases where 
there is a profuse, watery diarrhea, or in which there is pro¬ 
longed vomiting. In such cases the life of the patient fre¬ 
quently depends on being able to supply the body with fluids 
in some manner so that they may be retained. There are several 
methods at our disposal. 

Hypodermoclysis.—This is the giving of fluids into the loose 
subcutaneous tissues through a hypodermic needle by force of 
gravity. Sterile normal saline is the solution usually used. 
The site chosen for injection may be the abdominal wall, the 
thigh, or the region about the scapula. The apparatus needed is 
a graduated glass infusion bottle, rubber tubing, long large 
hypodermic needle, clamp, hot-water bags, gauze handker¬ 
chiefs, and adhesive tape. Exactly the same precautions as to 
sterility should be observed as for a surgical operation. The 
fluid to be given, heated to ioo° F., is kept warm by surround¬ 
ing the bottle with hot-water bags and covering the whole with 
heavy towels. The spot chosen for the injection is cleaned up 
with iodin and alcohol. All air is carefully expelled from the 
tubing and needle, and the tube clamped off. The needle is then 
inserted through the skin and run for some distance beneath 
the skin in the subcutaneous tissue. The clamp is then removed 


' 92 TEXTBOOK OF PEDIATRICS FOR NURSES 

and the fluid allowed to run. As it usually takes from one to 
two hours for the desired amount of fluid to flow, the needle 
and surrounding tissues may be covered with sterile gauze 
handkerchiefs, strapped in place with adhesive. A strap of 
adhesive may also be used to hold the tubing firmly in place, so 
as to prevent the needle from slipping out. As the fluid flows 
in faster than it can be absorbed, a swelling gradually forms 
about the point of injection. The nurse can hasten absorption 
by gentle massage of this swelling. 

Intravenous Injection.—This is similar to the subcutaneous 
administration just described, except that the fluid is injected 
directly into the circulation by running the needle into a vein. 
This is a more rapid method than the former, in spite of the 
fact that a smaller needle is used. It often requires consider¬ 
able skill to introduce a needle into the vein of an infant, and 
recently it has become customary to introduce fluids by run¬ 
ning a specially constructed needle through the anterior fon¬ 
tanel into the longitudinal sinus—a large vein running close to 
the surface. Glucose solution, as well as normal saline, is 
given by the intravenous method. 

Intraperitoneal Injection.—A rapid and relatively painless 
method of giving saline solution is to inject it directly into the 
peritoneal cavity. Care is taken that the bladder is empty, the 
skin below the umbilicus is cleaned up and a blunt needle 
pushed through the abdominal wall into the peritoneal cavity. 
With proper care, no injury to the intestines results. From 3 
to 8 oz. (75 to 250 c.c.) of sterile saline solution may be given 
this way for several days in succession. This also should be 
regarded as a surgical procedure and carried out with full 
surgical technic. 

Nasal Drip.—This method, which has but recently come into 
general use, is extremely valuable in giving fluids. A very 
fine rubber catheter is passed through the nose into the stomach 
and is held in place by strapping the catheter to the upper lip 
or cheek with adhesive. This catheter is connected by rubber 


INFANCY AND CHILDHOOD THERAPEUTICS 93 

tubing to an infusion bottle. In the tubing is placed a drop 
counter. From 10 to 20 drops a minute of water or glucose 
solution may be given in this way over a considerable length of 
time. In order to prevent interference with the tube, the child’s 
hands should be fastened to the bed by means of muslin bands 
about the wrists. The tubing should be well lubricated with 
albolene to prevent injury to the delicate membranes of the 
nose; and where the tube is retained for considerable time, it 
should be changed each day from one nostril to the other. 

Rectal Drip.—The so-called Murphy drip consists in giving 
fluids into the rectum through a fine catheter so slowly that they 
are absorbed rather than expelled, as in the case of an enema 
which is given more rapidly. About 15 drops a minute may 
be given in this way. The fluids are kept warm by means of 
hot-water bags hung about the container which holds the fluids. 

Rate of Flow of Fluids .—-The simple glass device, which is 
used to measure drops when fluids are given by nose or rectum, 
is fairly accurate; however, particularly in giving glucose solu¬ 
tions, there is a tendency for the rate to decrease gradually 
after a half hour or so. For this reason frequent readings 
should be taken to make sure that the flow is at the proper rate. 
There is a simple way to check up on this rate. Fifteen drops 
per minute are approximately equal to 2 oz. (60 c.c.) per hour. 
If more than 2 oz. has flowed in an hour, the rate of 15 drops 
per minute has been exceeded. More often less flows than is 
expected, due to the gradual diminution in the flow. 

Transfusion.—The giving of blood into the vein of the 
patient is finding increasing fields of usefulness. It is also be¬ 
coming a relatively simple operation. Blood from the donor 
is drawn into specially prepared flasks or syringes. A needle 
is then inserted into the patient’s vein and the blood adminis¬ 
tered by means of a syringe. Transfusion is valuable in hem¬ 
orrhage from many causes, and in certain toxic conditions. 

Lavage.—Washing of the stomach by means of a tube 
passed through the mouth and down the esophagus is a rela- 


94 TEXTBOOK OF PEDIATRICS FOR NURSES 

tively simple and very valuable procedure. It is used in cases 
of poisoning and in many cases of indigestion with vomiting. 
It always precedes gavage, which is the giving of food by tube. 
The apparatus used consists of a funnel, holding about 4 oz., 
attached to three or four feet of rubber tubing, which in 
turn is connected by a piece of glass tubing to a rubber catheter 
or stomach tube. One needs in addition a medicine glass con¬ 
taining glycerin, a mouth gag, a rubber bib, a curved basin, a 
bowl and a pitcher containing fluid to be used in washing the 
stomach. 

The child is securely wrapped to avoid a struggle and is pro¬ 
tected by the rubber bib. The stomach tube is moistened with 
glycerin. The first finger of the left hand is slipped in at the 
angle of the mouth and the tongue held down. Then with the 
right hand the tube is slipped quickly into the mouth. When 
the tip hits the posterior wall of the pharynx, it turns and slips 
readily into the esophagus. The tube is then pushed rapidly 
until it reaches the stomach. One must, of course, be sure that 
the tube is in the esophagus and not in the trachea; if in the 
latter, there is a rush of air through the tube with each respira¬ 
tion, which is readily recognized. If in the trachea, the tube 
must be promptly removed. This, however, is an accident 
which rarely happens as it is in fact very difficult to 1 introduce 
a tube into the trachea. 

When one is sure the tube is in the stomach, the washing 
commences. For this, either water or a solution of sodium 
bicarbonate is usually used. The funnel is held two feet above 
the patient, and several ounces of fluid poured in. The tube is 
then lowered and the contents of the stomach siphoned off. 
This is repeated several times until the fluid comes away clear. 
Usually a quart of fluid is sufficient. If during the process the 
child starts to gag, vomiting can usually be prevented by pulling 
the chin sharply forward and upward. When the washing is 
finished, the tube is pinched tightly, to prevent the escape of 
fluids into the pharynx, and quickly withdrawn. 


INFANCY AND CHILDHOOD THERAPEUTICS 95 

Lavage is a procedure which the nurse may do under direc¬ 
tion of a physician. She should, however, never do the first 
lavage on a given patient, as there are occasionally children 
who present special difficulties. 

Gavage.—Tube feeding is carried out almost exactly like 
lavage. In fact, washing almost always precedes the adminis¬ 
tration of food. After the stomach has been thoroughly 
washed, the milk, or whatever food is to be given, is poured 
into the funnel and allowed to run into the stomach. When 
the desired amount has been given, the tube is removed as in 
lavage. The food should be given at body temperature. This 
method of feeding is used in premature babies who are too 
weak to nurse, in patients who are comatose and in many other 
cases where for some reason food cannot be taken in the usual 
way. When this method of feeding is used, the interval be¬ 
tween meals should be as long as possible. 

Inhalations.—These consist of steam, sometimes medicated 
with volatile substances. They are used in croup, bronchitis 
and other diseases of the respiratory tract. In order to be of 
value, the air breathed must be saturated with the vapor, so it 
is necessary to confine this to a small place. A good croup tent 
can be made by covering a crib with a double sheet. Heavy 
cord is run from the top of the head to the top of the foot 
of the crib, on each side, the double sheet drawn over these 
cords and fastened securely to the mattress all around. The 
vapor is introduced through a metal pipe from the croup kettle 
or vaporizer. These kettles must be carefully watched, as there 
is constant danger that they may be upset, or become clogged 
and explode. Those which are heated by electricity are less 
dangerous than those with an alcohol lamp. 

A simple emergency tent may be made by throwing a sheet 
over an umbrella. This method is particularly recommended in 
the case of a nervous, easily frightened infant, who may be¬ 
come terror stricken if alone in the ordinary tent. In such a 
case, the mother or nurse may sit in a comfortable chair with 


96 TEXTBOOK OF PEDIATRICS FOR NURSES 

the child in her lap. The umbrella is opened and fastened to 
the back of the chair, and over this is placed a sheet, so that it 
falls to the floor on all sides. The croup kettle is then placed 
on the floor at the nurse’s feet. In this way the nurse can con¬ 
stantly watch the vaporizer, and can judge of the intensity of 
the vapor. 

Plain steam may be used for inhalations, or it may be made 
more effective by the addition of various substances, as com¬ 
pound tincture of benzoin, menthol, alcohol, and so on. In 
using the ordinary croup kettle, these substances are dropped 
on to a pad of cotton at the top of the kettle, through which 
the steam passes. 

Irrigation of Ears.—The ears in childhood are particularly 
susceptible to infection, and often the ear-drum ruptures or is 
punctured and pus is discharged. The comfort of the patient 
and the speed of healing are much influenced by keeping the 
canal of the ear free from pus. To do this, the canal is 
syringed with some solution such as boric acid. If the patient 
is young, he is securely wrapped to prevent struggling, a piece 
of rubber sheeting is placed over the shoulder, and over this 
a towel. A curved basin is pressed firmly against the neck 
below the ear. The irrigation should be done with an all¬ 
rubber ear syringe. The outer ear is drawn firmly backward, 
and the tip of the syringe inserted well into the canal. The solu¬ 
tion is then forced sharply into the canal. This is repeated 
until the fluid which flows out is free from pus. About 6 oz. 
to each ear is usually needed. After syringing, the canal should 
be carefully dried and anointed with vaselin or some bland 
ointment to protect the skin from the irritating effects of the 
discharge. 

Drugs.—As was mentioned in the introduction to this 
chapter, drugs do not play a large part in the treatment of 
children. A few, however, are of value and they fall for the 
most part into' groups: 

Antipyretics, or drugs used to reduce temperature, are, as a 


INFANCY AND CHILDHOOD THERAPEUTICS 97 

rule, not as efficient for this purpose as cold sponges or baths; 
however, phenacetin and antipyrin often make the fever patient 
more comfortable. 

Sedatives, or drugs used to quiet the nervous system, are 
often of great value. Those most used with children are 
sodium bromid and chloral. The latter is usually given per 
rectum, as it is irritating to the stomach. 

Opiates, or drugs derived from opium, are used to relieve 
pain, to produce sleep and to stop convulsions. Those best 
adapted to infants and children are morphin, codein, and pare¬ 
goric. The first two are usually given hypodermically. 

Stimulants are occasionally needed. By far the best emer¬ 
gency stimulants for children are caffein and adrenalin. These 
are given hypodermically. Where stimulation of the heart is 
desired over long periods of time, the various preparations of 
digitalis are of value. 

Tonics are sometimes a help in anemia. Iron, either as 
bitter wine, or as reduced iron and preparations of arsenic, 
particularly Fowler’s solution, is used in these conditions. 
Tincture of nux vomica, often combined with some such bitter 
medicine as compound tincture of gentian, is sometimes used 
to stimulate the appetite in older children. 

Laxatives should be avoided wherever possible by the proper- 
regulation of the diet. Where a thorough cleaning-out is 
desired, preference should always be given to mechanical 
means, such as enemas or suppositories. If it is felt necessary 
to use a drug, the milder preparations are preferable to the 
violent doses of calomel and castor oil of our forefathers. 
Milk of magnesia for infants and, for older children, citrate 
of magnesia, fluid extract of cascara or syrup of rhubarb are 
perhaps as satisfactory as any preparations. 

Dosage.—The amount of any drug to be given depends on 
a number of factors, particularly the age and size of the child, 
and the particular reason for which the drug is given. One 
cannot lay down rules and say that the dose for an adult being 


98 TEXTBOOK OF PEDIATRICS FOR NURSES 

so and so much, the dose for a child will be such and such. 
Children need proportionately much less of some drugs and 
more of others than their parents. Moreover, no table of 
dosages can be regarded as absolute, as the individual child 
and the disease must be taken into consideration. But the fol¬ 
lowing table gives approximate doses for average children at 
various ages: 


Approximate Doses for Average Children at Various Ages 


Drug 

Six 

Months 

One 

Year 

Five 

Years 

Ten 

Years 

Adrenalin (i: 1,000 solution) ... 

3 

min. 

5 

min. 

10 

min. 

20 

min. 

Antipyrin . 


gr. 

1 

gr. 

2 

gr. 

3 

gr. 

Belladonna, tincture of. 


min. 

1 

min. 

3 

min. 

10 

min. 

Cascara, fluid extract of. 

5 

min. 

10 

min. 

20 

min. 

30 

min. 

Caffein . 

1 

gr. 

2 

gr- 

3 

gr. 

5 

gr. 

Chloral (by rectum). 

3 

gr. 

5 

gr. 

15 

gr. 

20 

gr. 

Cod-liver oil . 

10 

min. 

30 

min. 

1 

fl. dr 

1 

fl. dr. 

Codein. 

VoO 

gr. 

Vso 

gr- 

Yi 0 

gr. 

Ye 

gr. 

Digitalis, tincture. 

1 

min. 

3 

min. 

5 

min. 

10 

min. 

Fowler’s solution (arsenic).... 

Ye 

min. 

U2 

min. 

3 

min. 

5 

min. 

Ipecac (as syrup of ipecac) .... 

3 

min. 

5 

min. 

10 

min. 

20 

min. 

Iron, reduced . 



/2 

gr. 

2 

gr. 

5 

gr. 

Iron, bitter wine of. 





34 

dr. 

1 

dr. 

Magnesia, citrate of. 





4 

oz. 

6 

oz. 

Magnesia, milk of. 

20 

min. 

I 

dr. 





Morphin ., 

YlOO 

» gr. 

y 5 o 

gr. 

Y20 

gr. 

Ms 

gr. 

Nux vomica, tincture of. 

J4 

min. 

1 

min. 

3 

min. 

5 

min. 

Paregoric . 

3 

min. 

8 

min. 

30 

min. 



Phenacetin . 

54 

gr. 

1 

gr. 

2 

gr. 

3 

gr. 

Rhubarb, syrup of. 



15 

min. 

1 

dr. 

2 

dr. 

Sodium bromid . 

2 

gr. 

3 

gr. 

5 

gr. 

5 

gr. 

Quinin . 


gr. 


gr. 

1 

gr. 

2 

gr. 


BIOLOGICAL PREPARATIONS 

In addition to drugs there is a group of bacteriological 
substances which are of increasing importance in treatment. 
These are the antitoxins, vaccines and serums. They are made 






























INFANCY AND CHILDHOOD THERAPEUTICS 99 

either from bacteria or are produced in the body in response 
to the action of bacteria. 

Diphtheria Antitoxin.—This preparation is produced by in¬ 
jecting horses with small doses of toxin from diphtheria bacilli. 
These doses are gradually increased until the animal develops 
a high degree of immunity. Blood serum from an animal so 
treated is standardized in such a way that a given amount of 
it contains a known amount of protective substance. The 
strength of the serum is measured in units. The antitoxin 
may be given subcutaneously, intramuscularly or intravenously, 
depending on circumstances. It is used in the treatment of 
diphtheria, being given as early as possible in the course of the 
disease. An average dose for a year-old child in the first 
day of the disease would be 3,000 units. It is also used pro- 
phylactically to prevent the development of the disease in per¬ 
sons exposed. In this case 1,000 units or less are given. The 
protection afforded by such a dose lasts only a few weeks. 

Diphtheria Toxin-Antitoxin.—Diphtheria toxin-antitoxin 
treatment, if carried out on a large scale in our schools, would 
soon put an end to epidemics of diphtheria. It has been 
found that humans, as well as horses, can be made to de¬ 
velop antitoxin, and that the antitoxin which an individual 
develops within himself gives him permanent immunity from 
the disease. By giving several injections of toxin combined 
with antitoxin the individual can be made immune with little 
or no unpleasant reaction. 

Antimeningococcus Serum.—This is prepared in a way 
somewhat similar to the diphtheria antitoxin. Its action, how¬ 
ever, is somewhat different in that it is effective only when it 
comes in contact with the bacteria causing the disease. As 
these organisms are found in the fluids surrounding the brain 
and spinal cord, the serum is injected by means of a lumbar 
puncture, or a puncture of the ventricles of the brain. The 
serum is of value only in that type of meningitis which is 
caused by the meningococcus. 



ioo TEXTBOOK OF PEDIATRICS FOR NURSES 


Vaccines.—Vaccines are killed cultures of bacteria, which 
are injected into the body in order to increase the resistance of 
the body to similar living bacteria of similar varieties. Their 
principal use in children is in cases of multiple infections of 
the skin, a condition known as furunculosis. In this case the 
vaccine is often prepared by growing bacteria found in the 
lesions, and making the vaccine from the organisms so grown. 
Such a preparation is spoken of as an autogenous vaccine. 

Small-pox Vaccine .—This is prepared from the vesicles 
which appear on cattle in the disease known as cowpox. This 
virus is collected with special precaution as to cleanliness, and 
is put up in tiny glass tubes, each holding enough for one vac¬ 
cination. A successful vaccination protects from small-pox 
for a number of years. 

Thyroid Extract.—Preparations of dried thyroid gland are 
put up in tablet form. These substances are of value in cases 
of cretinism. 

Insulin.—This preparation made from the pancreas is used 
in cases of diabetes. It is given hypodermically and its effect 
is so transient that it must be given frequently. 



CHAPTER X 

DISEASES INCIDENT TO BIRTH 




































































































































































































- 












































- 

















CHAPTER X 


DISEASES INCIDENT TO BIRTH 

The changes which take place in the body of an infant at 
birth are very great. He must change at once from a non¬ 
breathing organism, whose oxygen has been obtained from 
the mother’s blood through the placenta, to an air-breathing 
creature, using his own lungs. The course of the blood 
through his heart must change, and an opening between the 
chambers of the heart, necessary to fetal circulation, must 
close. Instead of being in an environment of constant tem¬ 
perature, he must now regulate his own temperature. Where 
his food was furnished him by the maternal circulation, he 
must now take his own nourishment by mouth. The waste 
products of his metabolism which were filtered off through 
the placenta must now be excreted by way of the intestines, 
the kidneys and the lungs. Many of these changes must be 
made in a few hours, some in a very few minutes if the 
child is to survive. It is not surprising then that occasionally 
infants fail to adapt themselves to their new surroundings 
and consequently die; the surprising thing is that such a vast 
proportion make the transition successfully. Some of the 
more important conditions incident to birth will be taken up 
in this chapter. 

Asphyxia Neonatorum.—The lungs of the unborn child are 
not air-containing. They are firm rubbery masses whose 
minute chambers must expand before they can supply the 
body with its necessary oxygen. Normally the child cries as 
soon as he is born, and this first cry opens the alveoli of the 
lungs and initiates respiration. A number of different things, 
however, may interfere with this process. The mother’s cir- 

103 


104 TEXTBOOK OF PEDIATRICS FOR NURSES 

culation may have been so poor, due to exhaustion, convul¬ 
sions, or other troubles, that the child is born deficient in 
oxygen and with too little strength to cry. Prolonged labor 
with undue pressure on the head may have produced the same 
condition. Finally the cord may be wrapped tightly around the 
neck or may be pressed upon, as is the case in breach presenta¬ 
tions, to such an extent that the circulation is cut off. When 
the child does not cry properly at birth and the lungs do not 
expand as they should, he is said to be asphyxiated. There 
are all grades of asphyxia from the child who needs but a few 
spanks to make him cry to the child who succumbs in spite 
of the most active measures of resuscitation. In the milder 
cases the child is blue and the muscles of good tone. In the 
severe cases the child is pale, relaxed, and may seem quite 
dead except for a faint beating of the heart. 

Treatment .—In each case the mouth and pharynx should 
be cleared of mucus by means of pledgets of gauze held in 
clamps or fingers. The baby is then usually held up by the 
heels and smartly slapped upon the back. If this is successful, 
well and good, if not, more strenuous means are employed. 
The child may be emersed in a tub of water at 105°, then in 
a tub of cold water. He should be kept but an instant in the 
latter, then returned to the hot tub. By repeated stimulation in 
this manner, respirations may often be started. Artificial 
respiration may be carried on while the child is in the warm 
tub, or without the use of emersions. An easy and effective 
method is to grasp the shoulders of the infant in the fingers 
of the left hand so that the head falls back on the back of the 
hand; the right hand is placed under the knees. The infant 
can then be folded up, the pressure forcing air from the lungs, 
and opened out, thus drawing air into the lungs. This pro¬ 
cedure should be carried out gently but firmly, about fifteen 
times per minute. The injection of adrenalin directly into 
the circulation is occasionally of value when the heart action is 
weak. It is most readily given directly into the heart itself. 


DISEASES INCIDENT TO BIRTH 


105 


Congenital Atelectasis.—Many cases of asphyxia recover 
entirely; in some, however, expansion of the lungs is not com¬ 
plete. The infant may breathe spontaneously and seem fairly 
well, but he nurses poorly, does not gain, and may become 
cyanosed on slight provocation, such as a stomach distended 
with gas. These infants cry feebly like premature babies and, 
as is the case with prematures, it is difficult to maintain a 
normal temperature. 

Treatment .—This must be carried on along two lines. First, 
the general condition of the patient must be kept at the highest 
possible point by careful feeding and maintenance of body 
temperature. Secondly, means must be taken to increase as 
far as possible the expansion of the lungs. To this end the 
child should be made to cry vigorously two or three times 
a day. This may be accomplished by spanking, or by slapping 
the soles of the feet. The patient needs constant watching 
as at any time attacks of cyanosis may develop and artificial 
respiration be necessary. The continuous use of oxygen over 
several days is valuable in cases which are markedly cyanosed. 

Jaundice.—Nearly one half of all babies develop jaundice 
during the first week of life. This yellowing of the skin 
usually appears on the third or fourth day and lasts for about 
a week. The smaller the child the more intense the staining 
is apt to be and the longer it is apt to last. This physiological 
icterus has little or no effect on the child’s progress and re¬ 
quires no treatment. There is a rare form of jaundice pro¬ 
duced by changes in the liver or bile ducts in which the color¬ 
ing appears at birth, or within a few hours after, and becomes 
increasingly intense. These cases end fatally in spite of treat¬ 
ment. 

Hemorrhages Due to Labor.—Prolonged labor often 
causes bleeding to occur under the infant’s scalp, producing 
a large swelling on one side of the skull, well back toward the 
occiput. Such swellings while disfiguring at first, need no 
treatment and disappear spontaneously in two or three months. 


106 TEXTBOOK OF PEDIATRICS FOR NURSES 

In breach presentations there is occasionally a hemorrhage 
into the sheath of the sternomastoid muscles, which causes 
a hard knotlike mass to develop about the center of this muscle. 
For a time the head may be drawn slightly toward the affected 
side, but gradually both the mass and the deformity disappear. 
No treatment is necessary, even massage being of doubtful 
value. 

Spontaneous Hemorrhages.—Certain infants have a ten¬ 
dency to bleed, totally apart from any difficulty or accident 
at birth. Bleeding may start at any time during the first 
weeks of life and may involve any of the tissues of the body. 
Hemorrhages from the cord, into the intestine, or from the 
mouth and nose, are most common. The bleeding is usually 
gradual and is difficult to control. The patient rapidly be¬ 
comes pale and prostrated. If untreated many of them die 
within a day or two. The course of the disease is always 
short, recovery or death in three or four days being the rule. 

Treatment .—This consists in transfusion with the blood of 
some healthy person. About 50 c.c. of blood may be given 
either intravenously, intraperitoneally or subcutaneously. In¬ 
jection into the umbilical vein would seem to be the most logical 
method of transfusion in the newborn. The dose may be re¬ 
peated several times if necessary. Nothing is more dramatic 
than the improvement of such an infant when transfused. 
Within a few hours he changes from a waxy, pale, stuporous, 
dying infant to a rosy baby who can nurse and cry. 

Ophthalmia Neonatorum.—Infection of the eyes at birth 
with the gonococcus is perhaps the most frequent infection of 
the newborn. The disease usually makes its appearance on 
the third day with swelling of the lids, redness of the mucous 
membranes of the eye and a watery discharge which soon be¬ 
comes purulent. The discharge soon becomes very abundant 
so that there is almost a continuous flow of pus from the eyes. 
If untreated, damage to the eyeball usually results with blind¬ 
ness as an outcome. In fact before the days of modern prophy- 


DISEASES INCIDENT TO BIRTH 


107 

lactic methods, about one-fourth of all blindness was due to 
gonorrheal ophthalmia. Prophylaxis consists in dropping into 
the infant’s eyes some 2 per cent silver nitrate solution. This 
method was devised by Crede and is called by his name. 

When the disease develops either through failure to apply 
the silver nitrate, or, as rarely happens, in spite of its use, 
the most energetic measures must be employed to save the 
sight. The patient should be strictly isolated and the nurses 
on the case should care for no other patient. These cases are 
very exacting and where possible there should be three nurses 
on duty, each caring for the patient for eight hours. The nurse 
should wear cap, gown and rubber gloves. She also should 
wear large goggles so as to make it impossible for her in a 
thoughtless moment to put her fingers to her eyes. All cotton 
or gauze used in wiping away discharges should be placed in 
a paper bag and burned. 

Treatment consists in keeping the eyes clean. The eyes 
should be irrigated with normal saline solution or boric acid 
solution as often as there is any accumulation of pus. If the 
lids are so swollen as to make irrigation difficult, iced com¬ 
presses changed every few minutes are useful. This procedure 
should not be continued for more than eight hours at a stretch, 
as the continued use of cold may do damage to the eyeball. 
Twice a day some antiseptic solution should be dropped into 
the eye; argyrol, 16 per cent, or silver nitrate, 2 per cent, 
are frequently used. Atropin is used to keep the pupil dilated, 
thus preventing adhesions. Sometimes only one eye is in¬ 
volved; in this case the good eye should be painstakingly pro¬ 
tected from infection. A watch crystal held in place by strips 
of adhesive plaster is valuable for this purpose. The general 
condition of the child must not be neglected, for a robust 
infant throws off the infection more readily than one who is 
puny. 

Other Infections.—The newborn infant is more susceptible 
to infection than at any other time of life, and should be 


108 TEXTBOOK OF PEDIATRICS FOR NURSES 

shielded accordingly. The umbilicus particularly affords an 
easy portal of entry for disease bacteria. It should, therefore, 
receive the most careful surgical care until entirely healed. 
Infections of the cord and surrounding abdominal wall, or 
widely scattered abscesses which occasionally occur in the new¬ 
born, are always serious. The treatment is surgical and de¬ 
pends upon the location of the lesions. 

HERNIA 

Umbilical Hernia.—Small hernias of the umbilicus are very 
common in poorly nourished infants under six months of age. 
When they develop in older children it is usually due to some 



Fig. 12.— Treatment of Umbilical Hernia. The adhesive plaster strap is 
drawn snugly, and extends well back in each flank. 

prolonged strain such as whooping cough. Treatment con¬ 
sists primarily in good feeding, as with gain in weight the tone 
of the abdominal muscles improves and the overlying fat tends 
to close the opening between the muscles. Of the mechanical 
measures of treatment, the best seems to be a wide adhesive 
strap applied across the abdomen snugly enough to hold the 
recti muscles together. A two-inch strip of adhesive is used, 








DISEASES INCIDENT TO BIRTH 109 

long enough to reach well down into each flank. The patient 
is placed upon his back on a table with his abdomen well ex¬ 
posed and his knees held down firmly by an attendant. One 
end of the adhesive strip is applied to the far flank and rubbed 
till it adheres tightly. The strap is then pulled snugly across 
the umbilicus. This obliterates the swelling and covers it 
with a fold of skin. The free end of the strap is then rubbed 
down in the near flank. Such straps should be changed each 
week. In this way small hernias usually close entirely in six 
weeks, larger ones in three months. Various types of pads 
which are sometimes strapped over the navel probably do more 
harm than good, for, while they keep the intestinal loop out 
of the hernia sack, they prevent the return of the abdominal 
muscles to their normal position and so retard the perfect heal¬ 
ing of the hernia. 

Inguinal Hernias. —Infants, particularly boys, sometimes 
develop inguinal hernias within the first few days of life. Most 
of these disappear spontaneously in a few weeks with no treat¬ 
ment at all. If they do not disappear the hernia may be re¬ 
duced and held in place by a simple worsted or stockinet truss. 
A band of either of these materials is passed around the waist 
and tied in a fore-in-hand knot. The end which tightens the 
knot is cut off, and the sliding end is passed between the legs 
and drawn down so that the knot presses firmly on the hernial 
swelling. The hernia is then reduced with the fingers, the truss 
pulled snug, and the free end tied behind to the band around 
the waist. Such a truss must be changed as often as soiled. 
The various rigid forms of trusses should be avoided as they 
irritate the child and are no more effective than the simpler 
and more comfortable type just described. 

ABNORMALITIES 

Harelip and Cleft Palate. —These congenital abnormalities 
may occur singly, but they frequently are associated. Modern 


no TEXTBOOK OF PEDIATRICS FOR NURSES 



Fig. 13.—Temperature Chart of 
Inanition Fever. Patient aged 8 
months, was given only the breast. 
Examination showed the mother 
had no milk. At X, fluids were 
administered by mouth and rec¬ 
tum with prompt return of tem¬ 
perature to normal. 


plastic surgery works wonders 
in the repair of these defects. 
Operation is usually postponed 
until the patient is at least six 
months of age, and these first 
months are critical ones. The 
child as a rule cannot nurse sat¬ 
isfactorily and must be fed with 
a dropper or Boston Feeder. 
Occasionally tube feeding is nec¬ 
essary. Mother’s milk should 
be used whenever possible, the 
mother expressing her milk as 
described in the chapter on Ma¬ 
ternal Nursing. 

Other Abnormalities. — Any 
part of the body may be in¬ 
volved in abnormal conditions. 
Some of these abnormalities are 
incompatible with life, the child 
dying in a few hours or days. 
Some, however, such as extra 
fingers or toes, are amenable to 
surgical treatment. 

Birth Paralyses. — Difficult 
labors, particularly breach pres¬ 
entations, and cases in which 
instruments are used, some¬ 
times result in damage to the 
nervous system which produces 
paralyses. There are numerous 


types, depending upon what part 
of the nervous system is injured. Hemorrhages from the 
vessels of the brain may cause early death, or, if the child sur¬ 
vives, widespread deformities of arms and legs. Stretching 





































DISEASES INCIDENT TO BIRTH 


hi 


or tearing of the nerves of face or arms may cause limited 
paralyses. In these cases marked improvement usually takes 
place during the first few weeks; after this time much can be 
done to prevent deformities by the use of massage. 

Inanition Fever.— Newborn infants cannot go for long 
without water and food. If for any reason one is deprived 
of fluids, as, for example, when the mother’s breast has gone 
dry, unknown to her, the infant reacts with an elevation of 
temperature which is known as inanition fever. This occurs 
most frequently during the first week of life, when a rise of 
temperature to 103° or 104° is not uncommon and should 
always make one question the milk supply. Besides the tem¬ 
perature, these infants show a dry powdery skin, rapid loss 
of weight, and prostration. If the condition is promptly recog¬ 
nized, and breast milk and water given, the return to normal is 
usually rapid. If the condition is allowed to continue, how¬ 
ever, a fatal outcome is not long delayed. In older children 
the condition is rare but when once established is usually much 
more stubborn, frequently calling for the administration of 
fluids intravenously or subcutaneously. 


















CHAPTER XI 

RICKETS AND SCURVY 

















































■. 







• 






























CHAPTER XI 
RICKETS AND SCURVY 


RICKETS 

Rickets is a widespread disease of infancy and early child¬ 
hood due to improper feedings. While the most noticeable 
changes it produces are in the bones and muscles, every tissue 
of the body is involved to some extent. It is the indirect cause 
of many deaths during the first two years, although it is 
seldom fatal in itself. It is preventable by proper care and 
feeding. 

Etiology. —While many factors such as lack of cleanliness, 
fresh air and sunlight contribute to the changes in rickets, the 
underlying cause, without which the disease does not occur, 
is a deficiency in the food of a certain vital substance. We 
may speak of this as the “antirachitic factor” for want of a 
better term. This antirachitic factor is found in the milk of 
most mothers, in lesser degree in cream from cow’s milk, in 
the yolk of eggs, and to a marked degree in cod-liver oil. 
When it is absent or decreased in the diet, rickets may develop. 
Children from six months to two years are most susceptible, 
although it may occur both earlier and later than this. It is 
more common in winter and spring; city dwellers are more 
susceptible than country dwellers; and the very poor, living in 
crowded tenements, more subject to it than those living in 
good hygienic surroundings. Colored infants and Italians in 
this country are particularly apt to develop it, as are premature 
infants of all races. 

Symptoms. —The earliest manifestations of rickets are fret¬ 
fulness, irritability and sweating, particularly of the head. 
These usually are noticed before the more marked symptoms 

115 


n6 TEXTBOOK OF PEDIATRICS FOR NURSES 


which occur in the bones. There is a deficiency of calcium and 
phosphorus in the body, in consequence of which the bones 
become soft, particularly at the ends where growth takes place. 
In an attempt to strengthen these weak places, the body lays 
down more bone, and swellings form at the ends of the long 
bones. These may be noticed on the chest, where the ribs 
join the cartilages, as a row of knobs. Their similarity in 
marked cases to a string of beads has earned for them the name 
of “rachitic rosary.” There are also enlargements at the 
wrists and ankles. The softened bones bend easily so that 
knock-knees, bow-legs and marked deformities of the chest are 
common. The skull also softens so that pressure over the oc¬ 
cipital region may cause it to bend and crackle under the 
finger. The anterior fontanel remains open long after the 
eighteenth month. Teething is usually much delayed, the first 
tooth often not appearing until the child is twelve months old. 
The muscles lose their tone and become flabby, producing pot¬ 
belly and a backward bending of the lower spine when the child 
sits. 

Complications.— Rachitic children fall an easy prey to all 
forms of infection. They acquire diseases more often than 
normal children, they throw them off with greater difficulty, 
and succumb to them in larger numbers. They are particularly 
susceptible to colds, bronchitis and pneumonia, from which 
latter disease many of them die. 

Diagnosis.— Diagnosis is made on the history of deficiency 
in the diet of the antirachitic factor, on physical findings such 
as beaded ribs and large epiphyses, on X-ray examinations off 
the bones, and on chemical examination of the blood for cal¬ 
cium and phosphorus. 

Prognosis.— Rickets in itself is not a fatal disease, but it 
contributes largely to the death-rate, as it makes the patient 
more susceptible to other diseases. It is curable with proper 
treatment, though not always without some deformity remain¬ 
ing. 


RICKETS AND SCURVY 117 

Prophylaxis. —Recent studies have shown that rickets is 
preventable. It seldom occurs in breast-fed infants when the 
mother is on a satisfactory diet, so that breast feeding when¬ 
ever possible should be carried out through the first eight or 
nine months. In artificially fed infants, one should avoid the 
use of diets low in fat, such as condensed milk. Finally all 
artificially fed infants, and even breast-fed infants, if there 
is any doubt as to the quality of the breast milk, should receive 
regular doses of cod-liver oil. One may start with 5 drops 
of the yellow Norwegian or American oil three times a day to 
a three months old baby, increasing gradually till at a year 
the infant receives one-half teaspoonful three times a day. 
It is not necessary to disguise the flavor in any way, for, 
strange as it may seem, they like it. In older children eggs are 
a safeguard. Sunlight and fresh air are also deterrents to 
rickets, a liberal coat of tan being an excellent insurance policy 
against the disease. 

Treatment. —Much that has been said under the head of 
prophylaxis applies as well to treatment. When a child is 
found to have rickets his whole manner of life must receive 
careful attention. Hygienic conditions, particularly with re¬ 
gard to fresh air and sunlight, must be made as near ideal as 
possible. The diet should be corrected so as to contain a 
liberal supply of good whole milk and, where age permits, 
fresh eggs. Cod-liver oil should be given, starting with a few 
drops, and increasing rapidly, if it does not upset the stomach 
or cause diarrhea, until the child is receiving a teaspoonful three 
times a day. In the warm months, the patient should receive 
daily sun baths. Infants may have their cribs placed on a 
porch or balcony, with a screen so arranged that the sun does 
not shine in the eyes, while the naked body gets the direct rays. 
The time of exposure requires careful supervision, care being 
taken that the child does not become burned. Older children 
may be allowed to run naked on the lawn or beach, the eyes 
protected by dark glasses if the glare is severe. In winter or 


n8 TEXTBOOK OF PEDIATRICS FOR NURSES 


in crowded districts of the city where sunlight is not available, 
much the same results may be obtained by the use of ultraviolet 
rays. The progress of the cure should in all cases be followed 
through frequent X-ray pictures or blood examinations. 

TETANY 

Tetany is a disease of the nervous system characterized by 
increased nervous excitability, a tendency to spasms of the 
larynx, hands and feet, and by convulsions. If not actually 
a manifestation of rickets, it is at any rate so closely connected 
with it that it must be discussed under the same head. 

Etiology. —The etiology is the same as rickets. Like rickets 
it depends on decreased utilization of the calcium in the blood. 

Symptoms. —Spasms of the hands and feet are the most 
common outspoken symptoms of the disease. The extended 
fingers are flexed on the hand which, in turn, is flexed at the 
wrist, while the thumb is held tight across the palm. In like 
manner the toes are sharply flexed. This combination is 
known as carpopedal spasm. Pain in the contracted extremi¬ 
ties is usually present, and the child is very fretful. Spasm 
of the larynx also occurs and gives rise to a peculiar crowing 
inspiration when crying which is so characteristic that a diag¬ 
nosis of tetany can be made without seeing the patient if this 
cry be present. General convulsions are also frequent. There 
are certain other signs which can be brought out on examina¬ 
tion which are useful in making a diagnosis. In these cases, 
tapping of the cheek causes twitching of the corner of the 
mouth. This is known as Chvostek’s sign. When carpal 
spasm is absent it may sometimes be induced by pressure on the 
upper arm. This is known as Trousseau’s sign. Erb’s sign 
is increased reaction of the patient to electrical stimulation. 
Finally examination of the blood for its calcium content is 
helpful. 

Prophylaxis. —This consists in the prevention of rickets. 


RICKETS AND SCURVY 


119 

Treatment. —The underlying rickets must be energetically 
treated. The spasms may often be relieved by the free use of 
bromids and antipyrin. Morphin or chloroform may be neces¬ 
sary where there are convulsions. Finally calcium should be 
given until the symptoms disappear. 

SCURVY 

Scurvy is a metabolic disease brought about by certain 
deficiencies in the diet. It is characterized by hemorrhages 
from the gums and under the periosteum of the bones, by pain 
and failure to gain. It is preventable. If recognized in time 
and energetically treated., no disease yields so readily. 

Etiology. —Scurvy occurs in artificially fed infants who re¬ 
ceive no raw food. Particularly it develops in infants fed on 
the so-called “infant foods” and on condensed milk. Boiled 
or sterilized cow’s milk is also a common factor. It is found 
in infants up to two years. Older children are not usually 
affected, although explorers and sailors who must live on diets 
lacking in vegetables and fruits are subject to it and often 
die of it. It is more common among the wealthy than among 
the poor, whose children usually “eat from the table” at an 
earlier age and so get a more varied diet. 

Symptoms. —Stationary weight on a diet providing sufficient 
nourishment is the most common early manifestation of scurvy. 
This is followed by pallor and irritability. Soon the gums 
become spongy and tender and bleed easily. Swellings occur, 
particularly just above the knees, which are caused by bleeding 
between the bone and the periosteum. These swellings are very 
painful and cause the child to hold his limbs stationary in a 
slightly bent position. So disinclined is he to move that the 
parents frequently conclude that he is paralyzed. This con¬ 
dition is known as pseudoparalysis. If untreated, hemorrhages 
occur under the skin and also from the mucous membranes 
and the condition becomes progressively worse till the child 


120 TEXTBOOK OF PEDIATRICS FOR NURSES 


dies of malnutrition, diarrhea, or some complicating infec¬ 
tion. 

Prophylaxis. —Every artificially fed infant should be given 
some raw food at least from the third month, unless some 
digestive disturbance makes this temporarily unwise. Orange 
juice is the most satisfactory and should be given daily, be¬ 
ginning with a teaspoonful in an ounce of water at three 
months, and increasing until the juice of half an orange is 
given at six or eight months. For older children vegetable 
juices, such as broth in which spinach, carrots, and string 
beans have been cooked, is valuable. Tomato juice may be 
used in the place of orange juice where strict economy is neces¬ 
sary. 

Treatment.— Regulation of the diet so as to contain as 
much raw food as possible, with fruit juices or green vegetables 
in as large quantities as the child can tolerate, constitutes the 
essential part of the treatment. Where a safe supply of raw 
milk is available this should be used in preference to boiled 
milk. Infants of six months may receive orange juice, 2 oz. 
three times a day. To older children the juice from green 
vegetables or purees of green vegetables may be given. As 
these children are very apt to have digestive upsets, they must 
be watched with care so that the new diet does not precipitate 
an attack of diarrhea. In changing and bathing them the 
most solicitous tenderness is necessary, as any motion may 
cause intense pain. Tonics such as reduced iron and cod- 
liver oil are indicated, as soon as the acute stage is passed, to 
overcome the anemia which is present and improve the gen¬ 
eral condition. 


CHAPTER XII 
DIGESTIVE DISORDERS 














CHAPTER XII 
DIGESTIVE DISORDERS 


DIARRHEA 

The various forms of diarrhea constitute a very large part 
of the illnesses of young children. They are the bulk of the 
hot weather work in pediatrics. As the different types require 
much the same treatment they will all be considered together. 

Etiology. —The popular name of “summer complaint” is 
well deserved by this group of diseases. They occur in their 
severe form almost exclusively in summer. Beginning in 
June the number of cases and their severity increase rapidly. 
July and August see the worst of the epidemic, while during 
September and October there are few new cases, and the more 
persistent of the old cases gradually clear up. The diseases 
are very widespread, occurring in all parts of the country. 
Crowded districts and those with poor hygienic conditions 
have the highest incidence. Neglect of maternal nursing, ig¬ 
norance of proper feeding methods, and carelessness in the 
preparation of food are important factors. No age is exempt, 
though children under two years provide most of the serious 
cases. In dysentery causative bacteria have been found: the 
several members of the dysentery group. But in the other 
diarrheas there is strong probability that no particular organ¬ 
ism is to blame. 

Symptoms. —No description of the symptoms of diarrhea 
can fit all the cases, for these vary in intensity from slight 
indisposition with a few loose stools to rapidly fatal cases in 
which bowel movements are almost continuous. But between 
these extremes lie the great majority of the cases. Vomiting 
is a common initial symptom, and may be present throughout 

123 


124 TEXTBOOK OF PEDIATRICS FOR NURSES 

the disease, particularly in dysentery. Colicky pain is another 
early symptom, an attack often preceding each movement. 
Fever is usually present during the first stages of the disease, 
but tends to drop to normal after the bowels have moved 
freely. In dysentery this temperature may persist for days. 
The character of the stools varies widely, and should be care¬ 
fully noted and described by the nurse. The first stools usually 
contain largely fecal matter, soon they become frequent, watery, 
green or olive-colored. If there is much solid material it is 
apt to be frothy. The odor may be sour or extremely foul. 
The dysentery stool is characterized by the presence of mucus 
and' blood. There may be definite streaks of blood on the 
diaper, but more commonly there is simply a pink tingeing 
of the mucus with which the stool is filled. There are never 
large hemorrhages. 

The general constitutional reaction varies with the severity 
of the attack, particularly with the loss of fluids from the 
system, and with the success of the measures taken to replace 
these fluids. Depletion of the fluids is shown by a dry loose 
skin and weak pulse. Loss of weight is usually rapid, and in 
the prolonged cases may be extreme. Prostration and nervous 
manifestations often ending in convulsions occur in the more 
severe cases. 

Complications. —Children who have suffered a severe attack 
of diarrhea are always in a debilitated condition and are 
particularly susceptible to attacks of other diseases. Otitis 
media, pyelitis, and furunculosis are common. For this reason 
the greatest care as to cleanliness and isolation should be ob¬ 
served in every case. 

Acidosis .—In any disease in which there is prolonged star¬ 
vation, or extreme' loss of fluids and salts from the body, 
particularly in severe diarrheas, a condition known as acidosis 
frequently develops. It shows itself in restlessness followed 
by stupor and by increased deep respirations. Its presence may 
be confirmed by certain tests on the blood and on the expired 


DIGESTIVE DISORDERS 


12 5 

air. Once a child has reached the stage of acidosis, the out¬ 
look is extremely grave, although not necessarily hopeless. 
The prompt administration of fluids intravenously, particularly 
glucose solution, will sometimes bring these patients out of 
their acidosis, when with proper handling of the underlying 
condition they may be brought back to normal. 

Prognosis.— It is true that a very large percentage of infant 
mortality is due to diarrhea, but, on the other hand, it is a 
condition from which practically every baby suffers at one 
time or another. The cases which prove fatal are usually 
those which occur in very small or debilitated children, or 
in children who have a succession of attacks, hardly recovering 
from one before being overtaken by another. Institutional 
babies, particularly if there is overcrowding, show an excep¬ 
tionally high mortality. 

Treatment.— At the onset of an attack of diarrhea it is 
usually wise to clear out the intestinal tract. With young 
children this is best done by giving a large enema, while with 
older children a mild saline cathartic such as citrate of magnesia 
is to be recommended. The use of castor oil or calomel in 
these cases leads to much unnecessary discomfort and should 
be discouraged. The child’s lack of appetite during the first 
twenty-four hours should be respected and nothing but water 
given. If there is much vomiting the stomach may be washed 
once or twice during this period, and a small quantity of water 
left in the stomach. Feeding is the important factor in all 
these cases and requires much care. Very mild attacks some¬ 
times clear up on boiled skimmed milk diluted according to the 
age of the patient, but in the great majority of cases sweet 
milk is badly borne and must be replaced by some form of fer¬ 
mented milk. The choice here is fairly large, and includes 
buttermilk, protein milk, reenforced protein milk, lactic acid 
milk, and various combinations and modifications of these. 
In addition older infants may be given curd, made by drying 
junket. The characteristic of all these foods is that they are 


126 TEXTBOOK OF PEDIATRICS FOR NURSES 


relatively low in carbohydrates and high in proteins. On such 
a diet a child may hold his weight, but will seldom gain. In 
consequence, as soon as the nature of the stools has sufficiently 
improved, an attempt should be made to add carbohydrates to 
the diet. Dextrimaltose is usually the safest form in which to 
start carbohydrates, and may be added to the diet in increasing 
amounts, if well tolerated, beginning with a quarter of an ounce 
to the day’s feeding. The care of cases in which there is much 
vomiting is particularly difficult. In these a long feeding 
interval with very small amounts of food should be tried at 
first. If vomiting continues it may be necessary to feed by 
gavage, first washing out the stomach. Where there is marked 
loss of fluid from the tissues, some means must be taken to 
replace this loss. There are several methods at one’s disposal, 
the choice depending on the particular features of the case. 
Nasal drip, intraperitoneal and intravenous injections are 
usually the most valuable. One should not hesitate to give 
two or three hundred cubic centimeters of normal saline or 
glucose solution each day over a considerable period, if the 
patient seems to be benefited thereby. The return to sweet 
milk and a general diet must be made with caution and at 
the first evidence of indigestion one should go back to' the 
protein diet. Convalescence is often hastened by a change of 
climate. A fairly dry locality where the nights are cool is 
advantageous. Relapses are common, and a child who has 
suffered a severe attack should, if possible, be removed from 
a hot climate for the following summer. During the period of 
convalescence the patient may be benefited by the administra¬ 
tion of some form of iron, to combat the anemia which is 
almost always present, and cod-liver oil as a general tonic. 

PROLONGED INDIGESTION 

This is a fairly common disease condition of early childhood, 
characterized by failure to gain, underdeveloped extremities, 
a large abdomen, and an irritable disposition. 


DIGESTIVE DISORDERS 


127 


Etiology. —The disease is most common during the second, 
third and fourth years. It occurs most commonly in children 
who have been on a diet containing a high proportion of fats 
and carbohydrates, although it may develop in carefully fed 
children whose digestion is inherently weak or has been dam¬ 
aged by attacks of acute indigestion or dysentery. It is much 
more common in bright precocious children than in the more 
phlegmatic. 

Symptoms. —These children are usually brought to the 
physician because they do not gain in weight, and because 
their arms and legs look thin and puny. Examination shows 
in addition a large gas-filled abdomen. The appetite is usually 
poor, although the patient may have a peculiar fondness for 
the foods which for him are specially harmful, such as mashed 
potatoes and cereals. The bowels usually alternate between 
constipation and diarrhea; in either case the stools are offen¬ 
sive, gray or clay-colored, and contain much mucus. Much 
gas is passed per rectum. It is characteristic of the disease 
that the abdomen is considerably larger in the evening than 
in the morning, due to the accumulation of gas. These chil¬ 
dren are fretful, contrary and generally hard to manage. They 
tire easily of any occupation, physical or mental. But they 
are bright, clever, and affectionate in spite of their handicap. 

Prognosis. —The outlook in these cases is for an illness of 
many months, with but very slow improvement and many re¬ 
lapses. Most of the patients ultimately recover although it 
is doubtful if the intestinal tract ever is as strong as it 
should be. 

Treatment. —Absolute cooperation between the family and 
the physician is necessary if anything is to be accomplished 
in these cases. Neglecting the dietary regulations for one day 
may undo what weeks of careful feeding have accomplished. 
Often these patients improve only when separated from the 
family entirely and placed in the hands of a competent and 
conscientious nurse. Treatment consists in a diet low in 


128 TEXTBOOK OF PEDIATRICS FOR NURSES 


carbohydrates and fats, and consequently high in proteins. 
Such a diet is unattractive to the child, and great strength of 
character is necessary to hold him to it. Buttermilk or protein 
milk, junket made from skimmed milk, lean beef, broth from 
beef or lamb, and an occasional piece of dry toast from stale 
bread form the basis of the diet for the first weeks. If there 
is much gas or troublesome constipation, enemas are of value, 
but every effort must be made to so regulate the bowels that 
they move twice daily without assistance. Massage of the 
abdomen is often of value in this regard. As the nature of 
the stools improves and the amount of gas diminishes, carbo¬ 
hydrates in the form of well-cooked cereals may be added; 
then eggs may next be given. Green vegetables and stewed 
fruits may then be tried. Sweet milk and any form of sugar 
should be withheld for a long time. The daily life of the child 
must be carefully regulated so as to provide sufficient periods 
of rest and avoid fatiguing play. 

CYCLIC VOMITING 

Cyclic or recurrent vomiting is a metabolic disease of child¬ 
hood, characterized by vomiting attacks of several days’ dura¬ 
tion, occurring at frequent intervals. 

Etiology. —The disease is most prevalent from the third to 
the twelfth year. Girls are more frequently attacked than 
boys. It is usually found in the children of highly neurotic 
parents. It seems to be due to an inability of the body to 
balance properly the amount of sugar in the body tissues. 
At any rate, this sugar is found to be surprisingly low just 
before and during an attack. 

Symptoms. —The individual attacks frequently come on 
when no assignable cause can be found, although there may 
be some slight indisposition such as a cold in the head or 
fatigue from a children’s party to inaugurate the attack. The 
child for a few hours may be droopy and show dark circles 


DIGESTIVE DISORDERS 


129 

under the eyes. Vomiting then commences, the vomitus at 
first being food, later thick, ropy mucus, often bile-stained. 
The vomitus is frequently blood-streaked, and in severe cases 
is occasionally fecal. With the vomiting the child becomes 
prostrated, the pulse becomes weak. There is usually consti¬ 
pation and the urine is scanty. The patient may complain 
bitterly of thirst, but as each attempt to drink causes a violent 
vomiting attack the patient often refuses anything by mouth. 
In three or four days the vomiting ceases, small amounts of 
food are taken without discomfort, and a surprisingly rapid 
return to health is made. 

Prognosis. —Very few of these children die, although many 
of them seem on the verge of death during each attack. As 
puberty is approached, the attacks as a rule become less severe 
and finally disappear entirely. They are apt to give place in 
adult life to headaches. 

Treatment. —Between attacks these children should be care¬ 
fully guarded from fatigue and excitement. Special care 
should be taken that their diet be rather low in fats but other¬ 
wise well balanced. If premonitory symptoms develop, it is 
well to put the child to bed and give an enema. Glucose solu¬ 
tion should then be given by Murphy drip in as large amounts 
as the child will retain. In this way attacks may sometimes be 
aborted. Once the vomiting has begun, no attempt should be 
made to give food or drink by mouth. Fluids, either glucose 
solution, bicarbonate of soda or normal saline, should be 
introduced per rectum, intraperitoneally or subcutaneously. 
The comfort of the child depends very largely on the amount 
of fluids which can be introduced by these means. Morphin 
is sometimes necessary on the third and fourth days if there is 
marked restlessness. 


PYLORIC STENOSIS 

This is a disease of infancy in which the muscle fibers which 
normally constrict the passage from the stomach into the small 


130 TEXTBOOK OF PEDIATRICS FOR NURSES 

intestine are for some reason much overdeveloped and prevent 
to a large extent the passage of food from the stomach. 

Etiology. —The disease usually begins during the first three 
months of life. It is much more common in boys than in girls. 

Symptoms. —Vomiting is the most marked symptom of the 
disease. This may come on at any time after the ingestion of 
food. It is usually projectile in character, the vomitus being 
forcefully expelled sometimes to quite a distance. Food may 
remain a long time in the stomach as can be shown by lavage 
when no food has been given for many hours. The muscles of 
the stomach are increased in strength by their efforts to force 
food through the pylorus, and the contractions of the stomach 
can be watched through the thin abdominal wall, moving as 
waves from left to right across the upper part of the abdomen. 
As little food reaches the intestines there is severe constipa¬ 
tion and scant urination. Loss of weight is always marked 
in cases which have persisted for any length of time. 

Prognosis. —The disease is always a serious one, usually 
requiring an operation in the more pronounced cases. 

Treatment. —In cases seen early, careful feeding with small 
amounts of breast milk at long intervals should be tried. 
In cases where breast milk is not available, reenforced protein 
milk sometimes gives excellent results. If vomiting persists, 
the stomach should be washed at feeding time, to remove the 
residue from the preceding meal, and the new feeding given 
by tube. If this treatment results in improvement, no opera¬ 
tion is necessary; if, however, the patient continues to go down 
hill, he should be operated upon before his condition gets too 
poor to withstand the operation. The surgical procedure con¬ 
sists in cutting the constricting muscle fibers of the pylorus 
without cutting through the mucous membrane lining the 
stomach or intestines. As soon as the patient has reacted from 
the anesthetic, feeding with small quantities of breast milk 
may be started. While the mortality from the operation itself 
is high, due to the debilitated condition of many of the patients 


DIGESTIVE DISORDERS 


131 

at the time of operation, those who survive the operation itself 
usually make a rapid return to normal. 

INTUSSUSCEPTION 

This is a relatively rare condition of infancy and early 
childhood. Its importance lies in the fact that the life of the 
patient may depend upon its prompt recognition. The lesion 
consists in the slipping of one portion of the intestine into an 
adjacent portion; the enveloping band of intestine then clamps 
down, causing obstruction and frequently gangrene of the 
constricted portion. 

Symptoms. —Pain is an early and prominent symptom. It 
is usually intermittent, colicky, and of great severity. Vomit¬ 
ing is also severe. The first few stools after the onset may 
be fecal but afterward they contain little but mucus and blood. 
The blood is bright red, and may be passed in large quantities. 
Prostration comes on early and is extreme. As a rule the ab¬ 
domen is soft, and through the wall can be felt a sausage-shaped 
mass caused by the intussusception. Without operation the 
patient usually goes down hill rapidly and dies in a few days. 

Treatment. —This is entirely surgical, and consists in slip¬ 
ping the outer, constricting portion of the intestine back from 
the constricted portion. When the condition has existed for 
some time, and gangrene of the inner portion of bowel has 
set in, it is necessary to remove the gangrenous portion of 
bowel entirely, sewing together healthy intestine above and 
below the removed portion. In any case the operation is a 
very serious one and the mortality high. 

OTHER CAUSES OF VOMITING 

In addition to those conditions already mentioned, there are 
many others in which vomiting is a prominent symptom. 
Many of these conditions are discussed at length elsewhere, 
but in order to bring them together the various types are here 
given in table form : 


Vomiting 


132 TEXTBOOK OF PEDIATRICS FOR NURSES 


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CHAPTER XIII 
INFECTIOUS DISEASES 










CHAPTER XIII 


INFECTIOUS DISEASES 

ISOLATION 

One of the most important phases of the care of com¬ 
municable diseases is their isolation. By this is meant the 
shutting off as far as possible of all avenues by which the dis¬ 
ease may be transmitted to others. If we knew exactly how 
each disease was conveyed from one person to another, isola¬ 
tion could be made more definite and probably simpler than 
we can now make it. Furthermore, if germs were large enough 
to be seen with the naked eye it would be relatively easy to 
prevent their spread. But such is not the case. We know 
some of the ways in which diseases may be communicated, 
but we cannot say that these are the only ways. We do not 
even know the nature of the agents which cause some of the 
diseases to say nothing of seeing them. And so in isolating 
a patient we must try to think of every possible way in which 
the disease might be spread, and then prevent its transmission 
in those ways. When we come down to the application of 
isolation in a particular case of an infectious disease we find 
that, while the physician in charge outlines the measures to be 
taken, it is the nurse who carries them out. So she must be 
thoroughly familiar with these methods. 

The Patient’s Room. —The patient should have a room to 
himself. It should be light and well ventilated and screened 
against insects. If possible it should have a bathroom avail¬ 
able not used by others. The room should contain no drap¬ 
eries or rugs or upholstered furniture. 

i37 


138 textbook of pediatrics for nurses 

The Nurse.— The nurse should wear cap, gown and mask 
so that she may be as completely covered as possible. Rubber 
gloves are essential where there are dressings to be done or 
treatments to be given in cases where there are purulent dis¬ 
charges. These gloves should be removed and kept in a disin¬ 
fectant solution when not in use. On removing cap, gown, 
or mask it must be remembered that the outer surface of these 
articles is contaminated, so that this surface must not come 
in contact with the uniform. On leaving the room the hands 
and face must be thoroughly washed with hot water and soap. 
The nurse should, of course, not eat in the sick room and 
should be very careful about touching soiled hands to mouth 
or eyes. 

The Doctor. —The same precautions apply to the doctor 
as to the nurse, only to a greater degree, as he must frequently 
go directly from this patient to another. 

Food and Dishes. —All dishes used by the patient should 
be kept for him alone, and should be thoroughly boiled before 
being returned to the general supply. Food remnants should 
be burned or otherwise disinfected. 

Sputum and Excreta.— Any discharges from the body may 
be dangerous, and so should receive special care. Sputum, 
and discharges from the eyes, ears, nose and glands should 
be caught on gauze, placed in paper bags provided for that 
purpose and burned. In some diseases, as, for example, 
typhoid fever, the urine and feces must be thoroughly mixed 
with some strong antiseptic before being disposed of. Diapers 
of infants with dysentery should also receive special care. 

Linens. —All gowns worn by the patient, nurse and doctor 
and all bed linen should be soaked in some antiseptic solution 
before being removed from the room, and should be boiled 
before being sent to the laundry. 

Books and Toys. —It is safest to give the patient only those 
playthings which one is willing to destroy at the termination 
of the illness. Books in particular have been known to harbor 


INFECTIOUS DISEASES 


139 

disease germs for a long time, and so should not be allowed 
to go from the sick room to other children. 

Release from Isolation. —When the patient is to be released 
from isolation he should be given a thorough soap and water 
bath and shampoo. He should then be dressed in clean clothes 
which have not been in the sick room. 

The bed linens should be placed in disinfectant solution and 
then boiled. The mattress may be brushed off with a whisk 
broom dipped in some antiseptic solution, and should then be 
sterilized by steam, or placed out-of-doors in the sunshine for a 
few days. The bedstead and furniture should be wiped with 
some sanitary fluid. The floors and woodwork should be 
scrubbed with soap and water, and the walls dusted with cloths 
moistened with some antiseptic. Furthermore the room should 
be thoroughly aired and as much sunlight as possible admitted. 

After scarlet fever, if one is to be perfectly safe, the wood¬ 
work should be repainted, the floors varnished, and the walls 
scraped and papered. 

Fumigation is still practiced in some cities after contagious 
diseases, but probably has no advantage over a thorough clean¬ 
ing. On no account should it be allowed to take the place 
of soap and water and fresh air. If used it should be in addi¬ 
tion to these. 

SCARLET FEVER 

Synonym. —Scarlatina. 

Etiology. —It is not known what germ or virus is the re¬ 
sponsible factor in producing the disease. We do know, how¬ 
ever, that it may be transmitted to a healthy person in three 
ways: (1) by direct contact with a sick person or carrier; 
(2) by means of clothing, toys, books, etc., which have been 
used by the patient; (3) by contaminated milk. Infants under 
two years are seldom affected, while children from five to 
ten years are most susceptible. Above ten years the number 
of cases rapidly diminishes. 


HO TEXTBOOK OF PEDIATRICS FOR NURSES 

Incubation Period. —This is from one to seven days, usually 
two or three. 

Symptoms. —The onset is usually abrupt with vomiting, 
pains in the head and back, and sore-throat. The temperature 
rises rapidly and the patient becomes drowsy and willing to 



Fig. 14.— Temperature Chart of Scarlet Fever. Rash is indicated by X. 

stay in bed. The rash from which the disease gets its name 
is generally noticed in from twenty-four to forty-eight hours 
after the onset. It appears first about the neck and spreads 
rapidly over the trunk and extremities. The color varies from 
a pale pink blush to the deep scarlet of a boiled lobster. The 
rash consists of minute, red elevations corresponding to the 
papillae of the skin, set upon a slightly less red background. 
The face does not show the rash, although the cheeks are 

































































INFECTIOUS DISEASES 


141 

very flushed. Around the nose and mouth there is a pale 
zone which is striking and characteristic. The rash disappears 
on pressure, to return again in a few seconds. Usually at 
the end of three or four days the rash begins to fade, and in a 
week or ten days from the onset of the disease desquamation 
begins. This peeling process takes several weeks. It consists 
of shedding the outer horny layers of the skin which have 
been killed by the eruption. Sometimes the skin comes off 
in small flakes, sometimes in large patches or strips. 

At the time when the papillae of the skin becomes swollen, 
those of the tongue swell also, and these red swellings pushing 
up through the heavy white coat which forms on the tongue 
produce the picture known as “strawberry tongue” which is 
characteristic of the disease. 

Complications. —Otitis media is the most common compli¬ 
cation and is one which sometimes leads to deafness. As it 
is frequently painless, the physician should make examination 
of the ears part of his regular routine so that the condition, 
if present, may be treated early. Adenitis, or swelling of the 
glands of the neck, is also frequent. Occasionally the glands 
go on to suppuration. Nephritis should always be watched 
for by making regular examinations of the urine. 

Prognosis. —Probably 90 per cent of all cases of scarlet 
fever recover. The outlook in a particular case depends on the 
age of the patient, the severity of his infection, and whether 
or not complications develop. 

Treatment. —The first and most important thing to keep 
in mind is the complete isolation of the patient. This depends 
almost entirely upon the nurse, for, while the physician out¬ 
lines the measures to be taken, it is the nurse who is constantly 
on hand to see that his orders are carried out. 

The patient should be in bed on a liquid diet until the fever 
has subsided, then the food should be gradually increased till 
by the third week, if no complications have set in, he is on his 
full diet. 


142 TEXTBOOK OF PEDIATRICS FOR NURSES 

Fever requires treatment only if it continues high, in which 
case it is best combated by cool sponges every three or four 
hours, or cold packs repeated three or four times daily. Cold 
compresses or an ice-cap to the head are also useful, par¬ 
ticularly when the patient is nervous and restless. 

The sore-throat should be treated by gargling or spraying 
with some mild solution such as Dobell’s. Care should be 
taken to keep the mouth and nose clean. 

Quarantine .—In uncomplicated cases the patient should be 
isolated for from three to five weeks, depending upon the 
local health regulations. He should, however, not be released 
from quarantine as long as there is any discharge from the 
ears or as long as there are discharging glands. 

MEASLES 

Synonyms. —Rubeola, Morbilli. 

Etiology. —The organism responsible for measles is un¬ 
known. This is particularly interesting when we realize that 
measles is one of the most widespread of all diseases, and one 
of the most contagious. The infecting element is contained 
in the secretions of the nose and throat, and is spread by sneez¬ 
ing and coughing during the early stages of the disease. It 
cannot be carried by a third person. Epidemics occur most 
frequently in winter and spring, although the disease is seen 
at all seasons. In countries like ours where there is much 
travel, measles is kept in circulation and most individuals are 
exposed and acquire the disease during childhood. As one 
attack usually protects against further attacks, we seldom see 
the disease in adults. In isolated communities, however, as 
in some islands, the disease may be absent for long periods, 
till whole generations of unprotected individuals have grown 
up. When measles is introduced into such communities, it 
attacks all ages and sometimes acquires alarming proportions. 
Nursing infants are rarely attacked if the mother has had 


INFECTIOUS DISEASES 


143 


the disease. In fact, measles before the sixth month is a 
most unusual occurrence. This, of course, is an argument in 
favor of maternal nursing. 

Incubation.— Eleven to fourteen days usually elapse from 
exposure to the onset of the first symptoms. 



,Fig. 15.— Temperature Chart of Measles. Rash is indicated by X, 
Koplik spots by K. 

Symptoms.— The onset of measles is usually gradual. There 
is running at the nose, some sneezing and cough, and conges¬ 
tion of the eyes. The child appears to have a cold in the 
head. Gradually these symptoms increase in severity, the 
cough in particular becoming dry and harsh. The child fre¬ 
quently is drowsy. There may be some fever. Usually on the 
third or fourth day the temperature becomes higher and a 

















































































144 TEXTBOOK OF PEDIATRICS FOR NURSES 

rash is noticed behind the ears and along the edge of the hair. 
This rash consists of dark reddish-brown spots, sometimes 
slightly raised and irregular in outline. The individual spots 
vary up to about an eighth of an inch in size, and are often 
more or less crescent-shaped. While they may be thickly scat¬ 
tered, they seldom run together. The skin is frequently swollen, 
particularly about the face, so that the child has a puffy look. 
The rash spreads downward to the face, neck, trunk, and 
finally to the extremities. By the third day it is usually at 
its worst on the face and is just showing on the hands and 
feet. At this point all the symptoms, fever, cough, drowsiness, 
and itching are at their height. They subside rapidly as the 
rash fades from the face. In addition to these readily recog¬ 
nized symptoms, there is one sign which is very helpful in 
making a definite diagnosis of measles. This consists in a 
peculiar eruption seen on the mucous membranes of the cheeks, 
known as “Koplik’s spots,” These are bluish white dots 
about the size of a pinhead and surrounded by a bright red 
halo. As they usually occur a day or more before the skin rash, 
they are a great help in early diagnosis. 

Complications. —Measles in previously healthy children of 
three years or over is not a serious disease, but in younger 
children, particularly in emaciated or sickly infants, it is so 
frequently followed by serious complications that it is never 
to be regarded lightly. Particularly is this so in institutions 
for young children, where the mortality from measles is some¬ 
times very high. 

Bronchopneumonia is to be suspected in any case of measles 
in which the temperature and cough continue after the usual 
time of subsidence. It is more common in the winter months. 
In summer the most dreaded complications involve the digestive 
tract, acute indigestion being particularly common. Otitis 
media occurs so frequently that the ears should be examined 
in every case. Some inflammation of the mucous membranes 
of the mouth is always present, but in puny infants and those 


INFECTIOUS DISEASES 


H5 


poorly cared for this condition frequently goes on to deep 
ulcerations of mouth or cheeks which may prove fatal. Measles 
so often lights up a latent tuberculosis that any child who is 
suspected of having been touched by this disease should be 
watched with special care, both during the disease and during 
convalescence. 

Treatment. —As soon as measles is suspected, the patient 
should be strictly isolated from all other children. Particularly 
is this true in institutions, where, during an epidemic, the first 
appearance of fever, snuffles, cough, or running eyes should be 
a signal for isolation. 

Young or delicate children who are known to be exposed 
should be given an injection of immune serum where such is 
available. Immune serum is obtained by taking blood from a 
healthy person recently recovered from measles and centri- 
fugalizing it, in this way separating the cells from the serum. 
This serum is given hypodermically, the amount varying with 
the age of the child. Aside from the use of this immune serum 
there is no specific treatment for the disease. 

The child with measles should be kept in bed in a large, 
well-ventilated room. He should, however, be out of drafts, 
and sudden changes in room temperature should be avoided. 
While the child should be shielded from bright light, it is 
a mistake except in the presence of unusual eye complications 
to darken the room. There is usually loss of appetite during 
the first few days and it is well to limit the nourishment to 
liquids or semi-liquids. As the appetite returns, soft foods may 
gradually be given. 

Especial care should be taken of the mucous membranes. 
The eyes should be bathed frequently with cold boric acid 
solution, and the lids rimmed occasionally with vaselin to pre¬ 
vent sticking. While it is unnecessary to forbid the child all 
use of the eyes, fine work such as reading or sewing should be 
prohibited not only during the height of the disease, but also 
during convalescence. A few drops of liquid albolene in the 


146 TEXTBOOK OF PEDIATRICS FOR NURSES 

nostrils often makes breathing easier, particularly in those 
cases where there is an excess of adenoid tissue. The mouth 
should be thoroughly but carefully cleansed after taking food, 
with some mildly antiseptic solution such as Dobell’s. The 
cough is usually very annoying and may require the use of a 
simple cough syrup such as Brown Mixture; occasionally a 
sedative is needed in addition, codein or paregoric being useful. 

During the height of the disease the child may have a warm 
sponge bath daily. If there is much itching, bicarbonate of 
soda sponges may be given. When the lesions are disappearing, 
the skin becomes dry, and many children are made more com¬ 
fortable by a rub with cocoa butter. 

The treatment of the various complications, such as broncho¬ 
pneumonia and otitis media, is the same as when these diseases 
occur independently of measles, and is considered elsewhere. 

Quarantine .—The patient should remain isolated for ten 
days from the date of the appearance of the rash. If there are 
complications such as otitis media or ulcerations of the mouth, 
the quarantine period must be continued till the patient is com¬ 
pletely recovered, as the discharges from the mucous mem¬ 
branes may in these cases convey the disease. 

RUBELLA 

Synonym. —German Measles. 

Diagnosis. —This is a disease of much more interest to the 
physician than to the nurse. It presents unusual difficulties of 
diagnosis, being frequently confused during the first few hours 
with measles on the one hand and scarlet fever on the other. 
As a rule, by the time a definite diagnosis is made, the child 
is well on the road’ to recovery, so that, while it may cause the 
physician some little concern, it seldom brings the patient to 
the condition where a nurse is thought necessary. 

Etiology. —The etiology is unknown. It is quite contagious, 
but one attack gives protection. 


INFECTIOUS DISEASES 


147 


Incubation Period. —This is from two to three weeks. 

Symptoms. —The patient may show a slight drowsiness and 
some coryza before the rash develops, but as a rule the first 
evidence of disease is the appearance of the rash. This con¬ 
sists of indistinct papules of a rosy red color. They appear 
first on the face, where they often run together, giving an even 
red blush to the face. Over the body and extremities the spots 
usually remain separate, with areas of normal skin between. 
The individual spots resemble closely those of measles, though 
they are slightly brighter in color. In fact the color is much 
more nearly that of a scarlet fever rash, and when the spots are 
very numerous, so that they run together, the rash is strikingly 
like that of scarlet fever. Usually the rash disappears in from 
two to four days. It may itch intensely. 

With the appearance of the rash, there is usually some en¬ 
largement of the superficial lymph glands, those just behind 
the ears being especially noticeable and affording a sign of 
some diagnostic importance. There is little or no sore-throat 
and no cough. The temperature as a rule is low, seldom going- 
over ioo° F., and disappearing as the rash subsides. 

Complications. —There are none. 

Treatment. —The child should be kept in bed and isolated 
until the diagnosis is made. By that time he is usually well 
enough to be up. If there is much itching, a soda bicar¬ 
bonate sponge or an oil rub sometimes gives relief. Further 
than this there is no treatment. 

Quarantine .—The patient should be isolated for two weeks. 

CHICKENPOX 

Synonym. —Varicella. 

Etiology. —It is not known what germ or virus is responsible 
for chickenpox. That this unknown substance is contained in 
the vesicles is known, however, for the disease may be trans¬ 
mitted by inoculation with their contents. The disease is 
almost always acquired directly from one suffering from it, 


148 TEXTBOOK OF PEDIATRICS FOR NURSES 

although it may possibly be carried by a third person. It is 
almost exclusively a disease of childhood as it is very highly 
contagious and most individuals acquire it early in their school 
life if they have not had it before. One attack gives immunity. 

Incubation Period. —Fourteen to sixteen days. 

Symptoms. —Chickenpox is usually a very mild affair. For 
a few hours before the rash appears there may be slight fever 
and restlessness, but usually the first intimation the parents have 
that there is anything wrong is when the rash appears. The 
rash is very characteristic and is hard to confuse with anything 
else. The individual lesion starts as a small red spot which 
grows in size and becomes somewhat elevated. This papule 
then develops a minute blister at its summit which gradually 
enlarges till it is about an eighth of an inch in diameter. These 
vesicles are at first filled with clear fluid and have a pearly 
appearance. The fluid later becomes grayish, and the center 
of the vesicle frequently collapses, giving a ringlike appearance. 
The vesicle at its height is surrounded by a narrow halo of 
inflamed skin. As the vesicle dries, it forms a brownish crust, 
which gradually loosens and falls off at the end of ten days or 
two weeks. Usually the skin below the scab is smooth and 
normal. Occasionally, however, when the vesicle has become 
infected, there is left a distinct pit which persists through life. 
It is interesting that in chickenpox not all of the lesions are of 
the same age, new ones being formed even as the old ones are 
drying up. Thus there may be seen at the same time papules, 
vesicles, and crusts. 

The lesions may occur anywhere on the body, even on the 
mucous membranes, but they are most numerous on the scalp, 
face, and trunk. 

Complications. —These are very rare except in very delicate 
children, or in cases where the skin is not kept clean and there 
is much scratching. In this event there may be infection of 
the lesions with the formation of ulcers or with the develop¬ 
ment of erysipelas. In healthy children kept reasonably clean 


INFECTIOUS DISEASES 


149 

complications almost never develop, and the outlook is abso¬ 
lutely good. 

Treatment.— The patient should be strictly isolated from 
persons who have not had the disease until all the scabs are off. 
The first day or two, while there is fever, should be spent in 
bed; after that the child may be up around his room. No 
general treatment is necessary. Itching may be lessened by 
the use of carbolic acid, 1 per cent, in vaselin or of zinc oxid 
ointment. Lesions which become infected may be treated with 
ammoniated mercury ointment and protected with sterile gauze. 

Every effort should be made to prevent scarring of the face. 
At the height of the disease, if the child is too young to refrain 
voluntarily, the hands should be restrained so that scratching 
is impossible. 





















































































■ 






























- * 








































■ H 
























































































































































CHAPTER XIV 

INFECTIOUS DISEASES —Continued 

















CHAPTER XIV 


INFECTIOUS DISEASES ( Continued ) 

DIPHTHERIA 

Synonym. —Membranous croup. 

Etiology. —The disease is caused by the bacillus diphtherise, 
otherwise known as the Klebs-Loffler bacillus after its dis¬ 
coverers. It is most common in the fall and winter months 
Children from two to ten years of age are most susceptible, 
although no age is exempt. From time to time widespread 
epidemics occur, but, in addition, in all large cities there are 
always a few scattered cases. The incubation period is from 
one to four days. 

Symptoms. —Diphtheria is a disease of many manifestations, 
but in general there are two groups of symptoms: those due 
to the local action of the organisms, and those caused by the 
action on various organs of the body of the toxins generated 
by the bacteria. The onset is usually gradual with slight sore- 
throat, some swelling of the glands of the neck, and a little 
fever. On examining the throat there is found a white or 
grayish membrane on the tonsils or the back of the pharynx. 
This membrane gradually spreads until often both tonsils, the 
uvula, and back wall of the pharynx are entirely covered. With 
the increase in the size of the membrane the toxic symptoms 
become more marked. Prostration increases and the patient 
becomes obviously ill. In favorable cases the membrane begins 
to break up and detach from the mucous membranes on about 
the sixth day. Some cases clear up rapidly with the disappear¬ 
ance of the membrane; in many, however, the toxic symptoms 
persist after the disappearance of the membrane, the heart par- 

153 


154 TEXTBOOK OF PEDIATRICS FOR NURSES 

ticularly feeling the effects of the bacterial poisoning. This is 
shown by a poor pulse and a dusky hue to lips and finger tips. 
Many such cases die of exhaustion, some of convulsions. 

Complications.— The diphtheria toxins sometimes attack the 
nerves with resulting paralyses. Of these the most common is 
paralysis of the soft palate which usually comes on about two 
weeks after the onset of the disease. It is noticed because on 
taking food by mouth the child regurgitates it through the nose. 
Paralysis of the eye muscles and weakness of the extremities 
often follow. Sometimes the heart is attacked, and for weeks 
the pulse remains poor, and the child must be closely watched to 
prevent any exertion whatever. Otitis media occasionally oc¬ 
curs and should always be watched for. 

Prognosis. —This depends very largely on now early treat¬ 
ment is started. Cases which receive antitoxin early almost all 
recover. The younger the patient the worse the outlook, other 
things being equal. Vomiting, a poor pulse, and paralyses 
are bad omens. 

Prophylaxis. —Diphtheria is such a serious disease and its 
epidemics reach such alarming proportions that everything 
possible should be done to protect the individual child from it 
and to check its spread. This means that all cases of diphtheria 
should be strictly isolated until repeated cultures of the throat 
have been found free from diphtheria bacilli. Those in con¬ 
tact with cases, if not themselves immune, should have protec¬ 
tive doses of antitoxin. Their nose and throat cultures should 
be negative before they are allowed to come in contact with 
other children, as it frequently happens that healthy individuals 
may harbor the virulent organisms on their mucous membranes. 
Such persons are called “carriers,” and are a danger to those 
with whom they come in contact. When several cases of 
diphtheria occur in a home or school, one should always sus¬ 
pect a carrier, and search should be made by taking nose and 
throat cultures from each individual. 

The Schick Test .—It is possible to tell whether or not a 


INFECTIOUS DISEASES 


i55 

person is susceptible to diphtheria. A small amount of diph¬ 
theria toxin is injected into the skin of the forearm. If there 
is natural antitoxin present in the system, this toxin is neutral¬ 
ized and no reaction follows. If, on the other hand, the person 
has no antitoxin, and is in consequence not immune to diph¬ 
theria, the injected toxin poisons the skin, causing a swollen, 
reddened area to appear in from one to two days which may last 
for a week or more. 

Active Immunization .—The immunity which is produced 
by the injection of antitoxin into a healthy person is known as 
passive immunity. It lasts for but a few weeks. But it is 
possible to produce a much more lasting immunity by the injec¬ 
tion of a mixture of toxin and antitoxin. This is known as 
active immunization, and is being carried out on a large scale 
on school children in some of our cities. If it lives up to the 
expectations of its users, it will largely eliminate diphtheria 
as an epidemic disease. The idea and its application are 
simple. To a given group of children, say a class in school, 
the Schick test is applied. Those who do not react to the test 
are immune and need no further attention. Those who do 
react are given the treatment. An accurately determined 
amount of toxin is all but neutralized with a corresponding 
amount of antitoxin and is injected subcutaneously. The anti¬ 
toxin protects the child from the poisonous effect of the toxin, 
but, strangely enough, the tissues start to work producing anti¬ 
toxin of their own. The body is thus stimulated by several 
injections at stated intervals and reacts by forming enough 
antitoxin to protect the child against diphtheria over a long 
period. This active immunization is built up rather slowly 
so that the method is not of value during epidemics. The in¬ 
jections produce few unpleasant symptoms in young children, 
but with older children and adults the reactions are sometimes 
severe. Hence it is well to immunize children in their early 
childhood. 

Treatment.— Diphtheria antitoxin is one of the few remedial 


156 TEXTBOOK OF PEDIATRICS FOR NURSES 

agents which have a definite rapid effect on the course of dis¬ 
ease. Given early and in appropriate doses it materially 
shortens the course of the disease and lessens the danger of 
complications. It is usually given subcutaneously or intra¬ 
muscularly, but in urgent cases should be given directly into 
a vein. In addition to this specific treatment the patient re¬ 
quires most careful nursing. Absolute rest should be secured, 
visitors should be excluded. A liquid diet should be given as 
long as there is any fever, after which the food may be gradu¬ 
ally increased. Special care is necessary to keep the mouth and 
nose clean. A mild gargle is sometimes indicated. 

LARYNGEAL DIPHTHERIA 

This condition, while really part of the picture of diphtheria, 
has not been mentioned in what has gone before because it has 
many peculiarities not shown by other types. As the name im¬ 
plies, this form of the disease consists in an invasion of the 
larynx by the diphtheritic membrane. The larynx may become 
involved in the course of a case of diphtheria which has already 
been recognized in the pharynx or on the tonsils. On the 
other hand it may start in the larynx with no membrane what¬ 
ever visible on the usual inspection of the throat. These cases 
are difficult to diagnose, and it is these which give the disease 
its special characteristics described below. Fortunately this 
type of the disease is much less common than the preceding. 

The onset is usually gradual. There is noticed a harsh 
cough, and the voice slowly becomes hoarse or is lost. Soon 
breathing becomes difficult until each breath is an effort. 
The child becomes pale and anxious. There is usually some 
fever, occasionally the temperature rising to 103° F. The 
pulse is feeble. If untreated, the symptoms become increas¬ 
ingly more severe till the child finally gives up the struggle for 
air, becomes stuporous, and dies. In untreated cases the num¬ 
ber who survive is small, while with the most energetic treat- 


INFECTIOUS DISEASES 


157 

ment the outlook is never sure, particularly in infants under 
one year, of whom nearly a half die. 

The treatment of laryngeal diphtheria is primarily the same 
as that of diphtheria elsewhere, that is to say antitoxin, given 
as soon as possible after the onset of the disease. In some 
cases this is all that is necessary; the hoarseness gradually dis¬ 
appears and the dyspnea never becomes alarming. In many 
cases, however, and in spite of early and repeated doses of 
antitoxin, the breathing becomes steadily more difficult. This 
is shown by the anxiety of the child, by the increasing noise of 
respiration, by the use of all the muscles of neck and thorax in 
the attempt to draw enough air into the lungs, and by a drawing 
in of the soft parts of the chest with each inspiration. Cyanosis 
may occur as a late sign of distress, but should not be waited 
for before interfering. 

Intubation. —When the larynx becomes so narrowed either 
by swelling of the mucous membranes or by diphtheritic mem¬ 
brane that there is recession of the soft parts of the chest on 
inspiration, intubation should be employed. This consists in 
the introduction into the larynx of a specially constructed 
tube of hard rubber which keeps the larynx open, and through 
which the child breathes. The necessary apparatus for the 
operation consists in an O’Dwyer intubation set: an instrument 
for introducing the tube, one for extracting the tube, and a 
set of tubes varied in size depending on the age and size of the 
child. 

Introduction of the Tube .—The child is securely wrapped to 
prevent struggling and is placed on a table so that the head 
extends slightly beyond one end. The child’s head is firmly 
held by the nurse who is seated at the end of the table. She 
can greatly assist the operator by raising or lowering the head 
so as to bring it into the best possible position for the intro¬ 
duction of the tube. The operator stands at the patient’s right. 
A mouth gag is placed in the child’s mouth, well back on the 
left side, and firmly held. The operator then slips the fore- 



158 TEXTBOOK OF PEDIATRICS FOR NURSES 

finger of the left hand into the child’s throat to get his land¬ 
marks, and when he is sure of his ground quickly slips the tube, 
on the introductor, into the larynx. When he is sure the tube 
is in place, it is steadied with the left forefinger while the in¬ 
troductor is removed. A black silk thread which is attached to 
the tube on introduction is left in place until it is felt that the 


Fig. 16.— Intubation. One nurse sits at the end of the table where she 
can hold the head in any desired position. The other nurse steadies 
the trunk. 

child is breathing satisfactorily through it, and that it is not 
going to be coughed up. Then the silk is cut, and pulled 
gently out from its hole in the tube. 

When intubation has been successfully accomplished, there 
is a marked change in the condition of the patient. At .first 
there is a severe attack of coughing brought on by the initiation 
of the tube. This often results in bringing up mucus or even 
membrane. When the coughing has subsided, breathing be- 




INFECTIOUS DISEASES 


159 

comes easy, the violent efforts of the child subside, and he 
frequently falls into a comfortable sleep. 

A child wearing a tube requires constant watching. Some¬ 
times an attack of coughing brings up the tube which may be 
expelled or may be swallowed. In such a case the physician 
should be called at once as it may be necessary to replace the 
tube. Occasionally the tube becomes blocked with membrane 
which has become loosened from the larynx, but in this case 
the child usually saves the situation by coughing up tube and 
membrane. One should be careful not to place the child in a 
position which would encourage expulsion of the tube. Thus 
the child should not be allowed to lie face downward or to hang 
over the side of the crib. 

Feeding of the tube patient is sometimes difficult, as food, 
particularly liquids, has a tendency to go down the wrong way 
and cause choking. This can sometimes be overcome by feeding 
thick foods such as cereals, junkets, or baked custard. Occa¬ 
sionally it is necessary to give fluids by means of a tube passed 
into the stomach through the nose. Most children, however, 
soon learn to swallow well with the tube in place. 

Extubation. —The tube is usually worn for from three to 
five days. When the temperature has come to normal, and it 
is felt that there is a fairly good chance that the child can get 
along without it, the tube should be removed. In order to avoid 
vomiting and the aspiration of the vomitus, no food should be 
given for six hours before extubation, and spasm of the larynx 
should be lessened as far as possible by the giving of a sedative 
an hour before operation. The operation itself is very similar 
to, though somewhat more difficult than, intubation. Patient, 
nurse, and doctor are in the same positions as before. The 
prongs of the extractor are introduced into the tube, expanded 
so as to grasp the inside, and the tube quickly withdrawn. If, 
as sometimes happens, severe dyspnea returns, the tube is re¬ 
placed. Sometimes several successive attempts at removal are 
followed by difficulty. These cases fortunately are rare, the 


160 TEXTBOOK OF PEDIATRICS FOR NURSES 

great majority of children being able to dispense permanently 
with the tube after a few days’ assistance from it. 

Tracheotomy. —Before the days of intubation, which is a 
comparatively recent operation, recourse was had in cases of 
laryngeal diphtheria to the much more radical procedure of 
tracheotomy. This consists in making an incision through the 
skin and fascia just above the thyroid gland, dividing several 
of the tracheal rings, and inserting a tracheotomy tube through 
which the child breathes. The tracheotomy tube consists of two 
curved silver tubes so made that one slips easily into the other, 
where it is held in place by a small catch. The larger tube has 
at its outer end a flat silver plate which lies against the neck 
and is supplied with loops for tapes to hold the tube firmly in 
place. This operation is still performed where intubation, al¬ 
though tried, proves unsuccessful. A tracheotomy set should 
always be on hand when an intubation is to be done. When a 
tracheotomy has been done, the inner tube is removed by the 
nurse every three or four hours for cleaning. The outer tube 
is removed daily by the physician for the same purpose. The 
tube is worn until the larynx has so far recovered that the 
child can breathe freely in the usual way. The tube is then 
removed and the wound allowed to heal. 

Quarantine .—After all symptoms have disappeared, cultures 
should be taken from the nose and throat. When such cultures 
prove negative for diphtheria bacilli on two successive days, 
the patient may be released from isolation. 

WHOOPING-COUGH 

Synonym. —Pertussis, 

Etiology. —Whooping-cough is highly contagious at all ages. 
Practically all exposed persons who are not protected by a 
former attack acquire the disease. The causative organism is 
thought to be the Bordet-Gengou bacillus, although the proof 
is not conclusive. At any rate this bacillus is frequently found 


INFECTIOUS DISEASES 


161 


in the plugs of mucus which are coughed up during a paroxysm. 
The infection is spread by droplets from the throat, scattered 
in coughing, sneezing, or talking. Contact must be fairly 
close, but it is not necessary that the patient whoop in order to 
spread the disease. In fact the most dangerous stage from the 
point of view of the spread of the disease is the catarrhal period 
before the whoop develops. Epidemics are more common in 
winter. 

Incubation Period. —Usually one to two weeks elapse from 
the time of exposure to the appearance of the first symptoms. 

Symptoms. —Attacks of whooping-cough vary widely in their 
speed of onset, intensity, and duration. The average case, how¬ 
ever, is divided into three more or less distinct stages: the 
catarrhal, the convulsive, and the convalescent stage. 

The catarrhal stage begins like an ordinary cold: there is a 
cough, some sneezing, and often a slight elevation of tempera¬ 
ture for a few nights. After a week or so, instead of getting 
better, as one would expect with a cold, the cough becomes 
worse. The coughs, instead of being single, and distributed 
more or less uniformly through the da) T , tend to group them¬ 
selves into coughing spells. The catarrhal stage lasts about 
three weeks. 

The convulsive stage is characterized by the fully developed 
paroxysm of coughing with its attendant whoop. The child 
usually feels the attack coming on and runs to a near-by object 
for support. The coughs are delivered violently and in close 
succession with no taking in of air till the child can cough no 
more, then there is a long inspiration which produces the whoop, 
and coughing commences again. The spell continues until a 
plug of thick stringy colorless mucus is brought up. Usually 
with infants and often with older children the attack is fol¬ 
lowed by vomiting. During the paroxysm the tongue is pushed 
far out with its edges rolled up to form a trough. The veins 
of the face and head become congested and the eyes bulge. 
After the attack the child is exhausted. Such attacks may occur 


162 TEXTBOOK OF PEDIATRICS FOR NURSES 


many times during the day and night. This stage usually lasts 
for three weeks. 

The convalescent period is marked by the subsidence of the 
cough. This stage usually lasts for three weeks also, but in 
winter it may drag on indefinitely. 

Complications.—It is these which make pertussis justly one 
of the most dreaded diseases of childhood. Older children 
usually come through an attack without difficulty, but in infants 
and young children the incidence of pneumonia and malnutri¬ 
tion is large and gives to whooping-cough its high mortality. 
Pneumonia comes on as a rule when the cough is beginning to 
subside and the vitality is at its lowest, due to the prolonged 
strain of coughing, vomiting, and loss of sleep. The outlook in 
such cases is necessarily grave, though by no means hopeless. 
Loss of weight during whooping-cough is sometimes very great, 
for, in addition to vomiting, there is often loss of appetite and 
diarrhea. For this reason patients with whooping-cough re¬ 
quire a most careful regulation of their diets. Hemorrhages 
due to the violence of coughing are fairly common. Convul¬ 
sions sometimes occur and make the outlook particularly bad. 
Hernia is not uncommon, the umbilical type being most fre¬ 
quent. 

Prognosis.—Given a healthy child of four years or older, 
whooping-cough while distressing is not dangerous. On the 
other hand, in poorly nourished infants below six months, the 
mortality is probably as high as 40 per cent. The older the 
child, other things being equal, the better the outlook. In 
summer the outlook is better than in winter because there is less 
likelihood of pneumonia. 

Treatment.—For the sake of the community the child with 
whooping-cough must be kept away from others who have not 
had the disease. This is a difficult matter, as the patient must 
be outdoors as much as possible. In many cities the board of 
health supplies each whooping child with a characteristic arm 
band which is supposed to act as a danger sign to other 


INFECTIOUS DISEASES 


163 

children. As most children who are susceptible are too young 
to know the significance of such a sign, it is at best of slight 
value, and the parents must keep a careful eye on the patient 
and his associates. 

Fresh air is a big factor in treatment. The patient should 
be outdoors as much as possible. When inclement weather 
makes this impossible, he should be indoors in well-aired rooms. 
When the convalescent period is especially prolonged, par¬ 
ticularly if the climate or the season of the year is unfavorable, 
a change to a warm climate is often of great advantage. A 
sea voyage sometimes brings prompt relief after a seemingly 
interminable period of coughing. 

Careful feeding is the second requisite, great care being 
necessary to maintain the nutrition. In some children eating 
brings on a paroxysm of coughing which in turn induces 
vomiting. This soon results in a marked loss of weight and 
weakness which is best combated by re feeding. If a meal is 
vomited, the child is allowed to rest for fifteen minutes and is 
fed again. 

Drugs are of use principally to insure sleep, although their 
sedative action is sometimes helpful during the waking hours, 
when the paroxysms are particularly severe. A combination of 
antipyrin and sodium bromid has seemed of value when used to 
lessen the paroxysms, and luminal sodium given at bedtime 
certainly makes the patient more comfortable. 

Vaccines prepared from the Bordet-Gengou bacillus, together 
with other bacteria often found in association with it, have been 
much used recently. They have not lived up to expectations 
and their chief recommendation in their present state of devel¬ 
opment seems to be that they are harmless. 

Quarantine .—The patient should be isolated for six weeks 
from the beginning of the whoop. Many children following 
an attack of pertussis whoop occasionally for a year or more 
with each fresh cold. At such times they cannot give whooping 
cough to others and need not be isolated. 


164 TEXTBOOK OF PEDIATRICS FOR NURSES 

MUMPS 

Synonym. —Epidemic Parotitis. 

Etiology. —That mumps is a contagious disease spread by 
contact, there can be no doubt, but what the organism is which 
causes it is not known. It is not nearly so contagious as 
measles, only a small proportion of those exposed developing 
the disease. Children from four to fourteen years of age are 
most susceptible, although no age is exempt. 

Incubation Period. —This is usually from two to three weeks. 

Symptoms. —In children mumps is usually a mild disease, 
with discomfort rather than illness. There may be loss of 
appetite and slight elevation of temperature for a day before 
the characteristic swelling is noted. Pain in the parotid region 
also precedes the swelling as a rule. On the second day a soft 
swelling, more easily seen than felt, is noticed on one side. 
This swelling has as its center the lobe of the ear, which is 
pushed outward from the head. Usually in anbther day or two 
the gland on the other side becomes involved. Occasionally 
the other side may not become involved at all; sometimes it 
becomes swollen after the first side has entirely subsided. 

Chewing and swallowing are usually painful and the mouth 
is dry. Occasionally acid foods cause pain, which gives rise 
to the household method of diagnosis of giving the suspect a 
pickle to eat. 

Complications. —These are rare, the disease running a mild 
course in the majority of cases. At or after puberty the tes¬ 
ticles are sometimes involved in boys, causing increased eleva¬ 
tion of temperature and severe pain. In girls the ovaries and 
breasts are occasionally swollen and painful. Other complica¬ 
tions such as suppuration of the parotid gland, deafness, 
nephritis, and meningitis occur but are fortunately very rare. 

Treatment. —There is no specific treatment for the disease. 
The patient should be confined to bed and given a liquid diet. 
Special care should be taken to keep the mouth clean. A warm 


INFECTIOUS DISEASES 


165 

flannel binder covering the swellings sometimes makes the 
patient more comfortable. Phenacetin or aspirin may be used 
for more severe pain. 

Quarantine .—The patient should be isolated for three weeks 
from the time the swelling is first noticed. 

SMALLPOX 


Synonym. —V ariola. 

Etiology. —Smallpox is an extremely infectious disease 
among the unvaccinated. Persons of all races and of all ages 
are subject to it. While scattered cases occur from time to 
time in large cities, the disease only becomes epidemic when 
through carelessness or willful disregard of rational precau¬ 
tions a considerable percentage of the population has remained 
unvaccinated in infancy or has failed to be revaccinated in 
later life. The disease is transmitted by material from the 
lesions of one infected. It may be spread by direct contact, 
or may be carried in clothing or by other objects which have 
been near the patient. It may also be carried by a third 
person. 

Incubation Period. —This is from ten to eighteen days. 
Most cases develop on the twelfth day after exposure. 

Symptoms. —The onset of the disease is usually sudden. 
Vomiting is frequent and is often accompanied by severe 
abdominal pain. There is headache which may be violent; 
pain across the small of the back is also extreme. In infants 
and young children, convulsions are usual. The temperature 
rises rapidly to 104° F. or higher, and remains elevated for 
the first four days. During this time there is marked drowsi¬ 
ness, sometimes deepening into coma. 

The rash which is the most characteristic feature of the 
disease appears on the third day. It shows first upon the 
forehead and wrists. It spreads rapidly to the rest of the 
face. In another day it comes out on the trunk and arms 


166 TEXTBOOK OF PEDIATRICS FOR NURSES 

Table of Contagious (highly infectious) Diseases 


Name 

Chickenpox 

(varicella) 

Diphtheria 

German Measles 
(rubella) 

Measles 

(rubeola) 

Incubation 

Days 

14-16 

2-5 

14-21 

11-14 

Onset 

Slight fever for 
24 hours 

Sore-throat, fever 

Malaise for few 
hours 

Gradual, coryza 

Eruption 

Papules, vesicles 
and scabs at same 
time 

None 

Pale red pinhead 
spots covering 
whole body 

Red flea-bite like 
*pots appearing on 
face, 2-4 days af¬ 
ter onset, spread¬ 
ing over whole 
body. 

Other 

Symptoms 

Slight fever, itch¬ 
ing 

Membrane, large 
cervical glands, 

prostration 

Slight fever, en¬ 
larged postauricu- 
lar glands 

Fever, cough, 
drowsiness, itch¬ 
ing, Koplik spots 

Complica¬ 

tions 

Superficial infec¬ 
tions 

Otitis media, lar¬ 
yngeal diphtheria, 
pneumonia, paral¬ 
yses, anemia 

None 

Pneumonia, otitis 
media, diarrhea 

Isolation 

Till scabs are off 

Till 2 successive 
:ultures have been 
negative 

Till positive diag¬ 
nosis is made 

10 days after rash 
appears 


while on the following day it involves the legs. Usually 
when the rash has spread over the whole body the temperature 
drops to normal. 

The individual lesion goes through numerous stages. It 
starts as a small red spot, this becomes hard and elevated, 
presently it contains fluid which later becomes purulent. The 
pustule in turn dries, leaving a scab at the end of two weeks 
from the beginning of the rash, loosens and drops off leaving 
a depressed discolored scar. When the rash is at its height 
the skin is intensely painful, while during the stage of the 
separation of the scabs, the itching is almost unbearable. 
The temperature which falls when the rash is fully developed, 
often rises again when the pustular stage of the eruption is 
reached. 

Complications.— Secondary infections of the skin, such as 
furuncles and boils, are common, particularly if the child is 
allowed to scratch. The eyes are often much inflamed. Laryn¬ 
gitis, bronchitis, and pneumonia often occur at the height of 
the disease, the latter being a frequent cause of death. 




































INFECTIOUS DISEASES 

Table of Contagious (highly infectious) Diseases— Continued 


167 


Mumps (epidemic 
parotitis 

Scarlet fever 
(scarlatina) 

Smallpox 

Whooping-cough 

(pertussis) 

14-21 

1-6 

10-18 

7-14 

Slight headache, 
pain at angle of jaw 

Sudden, vomiting 

Sudden, vomiting 

Gradual, cough 

None 

Red pin points every¬ 
where, except face; 
desquamation 

Papules, vesicles, 

pustules, scabs, 
scars 

None 

Swelling of parotid 
glands, pain, back¬ 
ache, loss of appe¬ 
tite 

Fever, prostration, 
5ore-throat, enlarged 
glands 

Pain, fever, itching 
All symptoms in 
tense 

Paroxysmal cough, 
vomiting, loss of 
weight 

Involvement of sex 
glands 

Otitis media, cellu¬ 
litis, nephritis, strep¬ 
tococcus, tonsillitis 

Skin infections, eyt 
involvement, pneu¬ 
monia, etc. 

Malnutrition, pneu¬ 
monia 

2-3 weeks 

3-5 weeks 

Till scabs are ofl 
and skin clean 

6-8 weeks 


Prognosis. —Among children unprotected by vaccination, 
about 30 per cent, of those who get the disease die. The 
younger the child and the more widespread the eruption, the 
worse the outlook. In those rare cases where vaccinated chil¬ 
dren acquire the disease, its course is usually very mild, the 
mortality being about 1 per cent. 

Treatment. —The patient should be isolated as completely 
as possible. All persons known to have been in contact with 
the patient who have not recently been successfully vaccinated, 
should be vaccinated. This applies with special force to the- 
nurse, the doctor, and to any others who must handle the 
child. 

During the first stage of the disease the effort is to relieve 
as far as possible the headache and backache. To this end 
cool sponges, and an ice cap to the head are useful, while drugs 
are often necessary, particularly to insure some rest at night. 

When the eruptive stage is reached the nursing becomes 
very difficult. The patient is covered with painful lesions 
so that all handling is resented. Later as the lesions become 
































168 TEXTBOOK OF PEDIATRICS FOR NURSES 


purulent the greatest care is necessary to prevent infection. 
Prolonged warm tub baths are useful at this stage. During 
the itching stage, the skin may be anointed with carbolated 
vaselin, or may be sprayed with a solution of carbolic acid in 
glycerine and water. It is frequently necessary to restrain the 
child’s hands to prevent scratching. 

Liquids and crushed ice should be given during the first 
stage, while later cereals and custards may be added. 

Quarantine .—The patient must be isolated until all of the 
scabs are off, and the underlying skin healed. 

Vaccination.— Artificial innoculation of a person with the 
virus of cow-pox is called vaccination. A successful vaccina¬ 
tion gives immunity to smallpox for a number of years. All 
children should be vaccinated during the first year, best dur¬ 
ing the first six months. They should then be revaccinated 
on entering school, and every five years thereafter. These 
later vaccinations seldom take, but should be carried out as a 
matter of safety. 

The left arm at the insertion of the deltoid is the point of 
choice for vaccination, but in girls, for cosmetic reasons, the 
leg just above or below the knee is chosen. 

The vaccination begins to take on the fourth or fifth day, 
although it is sometimes delayed till the tenth. A red spot 
appears in the course of the scratch, this enlarges and soon 
forms a vesicle filled with grayish fluid. As this begins to 
dry there is usually some local swelling and redness about it, 
and the patient may be feverish for a day or so. The glands 
in the axilla or groin are enlarged and tender at this stage. The 
reaction soon subsides and a hard crust forms which remains 
in place for a week or more, finally separating to leave a 
depressed pink scar. In time this turns white and is the 
mark of a successful vaccination. 

From the time the vesicle appears until the scab has sepa¬ 
rated the wound should be dressed daily. It may be sponged 
off with alcohol, powdered with boric acid, and covered with 
sterile gauze, held in place by narrow adhesive strips. 


CHAPTER XV 

INFECTIOUS DISEASES —Concluded 





















































































' 



















































































































CHAPTER XV 

INFECTIOUS DISEASES ( Concluded) 

INFLUENZA 


Synonym. —Grip. 

Etiology. —During the past few years the civilized world 
has been swept by a series of waves of epidemic influenza. 
The Pfeiffer bacillus has been named as the causative factor 
and is frequently found in secretions from the nose and throat 
of patients suffering with the disease. The malady is highly 
contagious, spreading with amazing rapidity through a com¬ 
munity and being carried readily from one part of the country 
to another. No age is immune, although in some epidemics 
children seem less apt to be attacked than in others. The im¬ 
munity produced by an attack lasts for about a year. Epidemics 
usually reach their height in winter, but in epidemic years scat¬ 
tered cases are encountered through the other seasons. 

Incubation Period. —This is short, seldom being more than 
a day or two. 

Symptoms. —It is probable that, during the last few years, a 
number of different conditions have been grouped with in¬ 
fluenza. Certain it is that no disease except syphilis has as 
varied manifestations as are credited to influenza. For ease 
of description the disease is usually separated into different 
types which may occur separately or may occur together. 

The respiratory type is characterized by fever, cough, and 
prostration. There is flushing of the face, particularly about 
the eyes. The throat is infected, and there may be small hemor¬ 
rhagic spots on the soft palate and anterior pillars of the tonsils. 
The cough at first is dry and harsh and often associated with 


172 TEXTBOOK OF PEDIATRICS FOR NURSES 

pain under the sternum. Soon there is free production of 
mucus which is thick and stringy and may give rise to a cough 
which is hard to distinguish from that of pertussis. This type 
when uncomplicated usually lasts for four or five days, al¬ 
though the cough may persist for weeks. 

The febrile type usually comes on suddenly with a high 
fever and nothing except an occasional reddening of the throat 
to give any clue as to the cause. The temperature may go to 
105° or 106 0 F., and be ushered in by convulsions or vom¬ 
iting. There is drowsiness and prostration, the patient usually 
resenting attempts to feed or care for him. The fever usually 
drops and the child returns to normal in three or four days, 
although in some cases there may be an intermittent fever 
for a week or more. The nervous manifestations may be so 
pronounced as to overshadow all other symptoms. This has 
led some authors to make a separate group called the nervous 
type. As these symptoms are due to the high temperature, 
it would seem that no good purpose is served by thus dividing 
the febrile type. 

The gastro-intestinal type is ushered in with severe vomiting 
which frequently persists throughout the course of the disease. 
There is high fever, reaching 104° or 105° F. Frequently 
there is a severe diarrhea accompanied by abdominal pain. At 
first there is marked restlessness which gives way as the patient 
becomes weaker to the quiet of exhaustion. After three or 
four days the vomiting becomes less, the fever subsides, and 
with the gradual increase in assimilation the patient recovers. 

Complications. —The high mortality credited to influenza 
during the past few years is due in large part to the com¬ 
plications which are unfortunately so common in the course 
of the disease. Pneumonia is a frequent and serious com¬ 
plication. It comes on at or soon after the height of the 
disease. A less serious though frequent complication is a 
bronchitis which may persist for weeks or months. This 
sometimes gives rise to an erroneous diagnosis of tuberculosis. 


INFECTIOUS DISEASES 


173 


Otitis media is so frequent with influenza that it might almost 
be classed as a symptom rather than a complication. Cervical 
adenitis occurs, particularly in those cases in which the upper 
respiratory tract is much involved. The enlargement is apt 
to continue for a long time, although it seldom goes to sup¬ 
puration. With this adenitis there is apt to be a slight after¬ 
noon rise in temperature, loss of appetite and weight and 
marked anemia. A tuberculin test is necessary to differentiate 
these cases from tuberculous adenitis. Meningitis following 
influenza is a rapidly fatal complication. 

Treatment. —The patient should be strictly isolated, those 
coming in contact with him wearing gauze masks to prevent 
infection. He should be in bed and on a liquid or soft diet. 
The taking of fluids should be encouraged. The bowels should 
move daily, milk of magnesia or aromatic cascara being used 
if necessary. Tepid or cool sponges are useful if the tem¬ 
perature is high or there is marked restlessness. Phenacetin 
or antipyrin are of value to make the patient more comfortable 
but should be promptly discontinued if there is any sign of 
pneumonia. Complications should be watched for, particularly 
the lungs and ears should be frequently examined. Compli¬ 
cations should be treated as when occurring independently. 

Where several members of one family or several patients 
in a ward are suffering from the disease, the effort should 
be made to isolate them as completely as possible, one from 
the other. In this way the danger of complications is lessened. 

Quarantine .—The patient should be isolated for ten days if 
no complications develop. 

MENINGITIS 

Meningitis, or inflammation of the brain coverings, may be 
caused by a number of different organisms. There are, how¬ 
ever, two main types: those due to the meningococcus; and 
the tubercle bacillus, which will be taken up separately. 


174 TEXTBOOK OF PEDIATRICS FOR NURSES 

Cerebrospinal Meningitis 

Synonym. —Epidemic Meningitis. 

Etiology. —The meningococcus is found in the spinal fluid 
of cases in the epidemics which occur every few years. It is 
also found in isolated cases occurring at times when no epi¬ 
demic is present. Epidemics usually occur in the winter or 
early spring. Children up to five years of age are most sus¬ 
ceptible. The disease is certainly contagious, although but 
mildly so. 

Symptoms.— The onset of the disease is sudden. The tem¬ 
perature rises quickly, there is vomiting, and headache. Often 
convulsions occur. The muscles become rigid which leads to 
a drawing back of the head, arching of the spine, and flexing 
of the arms and legs. The nervous system is extremely irri¬ 
table, so that loud noises, bright light or handling cause violent 
reactions, often even convulsions. There is usually delirium, 
at least at night. Food is taken poorly, and after a few days 
there is rapid emaciation. The bowels are usually constipated. 
Herpes of the lip is common, and hemorrhagic spots scattered 
over the body occur in some cases. Untreated cases go on in 
this way becoming progressively more emaciated for weeks. 
Most of them die, death being due to convulsions, marasmus, or 
some complicating disease such as pneumonia. The tempera¬ 
ture varies irregularly from subnormal to 103° or 104° F. 
Cases treated energetically from the onset usually show marked 
improvement in a week and may be convalescent in two weeks. 

Treatment. —The treatment of cerebrospinal meningitis 
with Flexners serum is one of the triumphs of modern medi¬ 
cine. It has decreased the mortality from about 75 per cent to 
less than 25 per cent: It has shortened the course of the dis¬ 
ease and lessened the amount of permanent damage to the ner¬ 
vous system. The efficacy of the serum depends largely on its 
early administration so one should be prepared to give it as 
soon as the diagnosis is made. The serum is given into the 


INFECTIOUS DISEASES 


175 

spinal canal by lumbar puncture, so that in suspicious cases 
one should have the serum ready to give when the initial diag¬ 
nostic puncture is made, so that, if the spinal fluid is character¬ 
istic of meningitis, the serum may be given at once without 
removing the needle. The usual procedure is to draw off as 
much cerebrospinal fluid as will flow, usually 20 or 30 c.c., 
then allow 10 c.c. of the serum to flow in under gravity. One 
or two treatments should be given each day until the tempera¬ 
ture comes to normal. The duration and intensity of treatment 
is also controlled by bacterial examination of the spinal fluid, 
persistence of living bacteria calling for continued injections. 

The nursing care of these patients is most important and 
difficult. Feeding must frequently be given by tube, in late 
cases almost invariably so. The bowels must be carefully 
watched and kept open by enemas. Distention due to gas or 
to retention of urine must be watched for. Great care is 
necessary to avoid local infections. Bed sores and ulcerations 
about the mouth can only be prevented by the most scrupulous 
cleanliness. 

Drugs such as chloral and the bromids are useful in lessening 
nervous irritability and producing sleep. Convulsions call for 
the prompt use of chloroform or the hypodermic administration 
of morphin. 

Quarantine .—The patient should be isolated until well. 

TUBERCULOUS MENINGITIS 

Etiology. —This form of meningitis which is caused by 
the tubercle bacillus occurs in children who have a tuberculous 
process elsewhere. Usually tuberculous glands or joints are 
present; occasionally it is part of a generalized, miliary infec¬ 
tion. It is most common in children under two years, although 
it may occur at any age. 

Symptoms. —Unlike epidemic meningitis, the onset is apt 
to be gradual. The child becomes fretful and cross and re- 


176 TEXTBOOK OF PEDIATRICS FOR NURSES 

sents handling. He vomits, the vomiting being without relation 
to the taking of food, and often projectile. If old enough the 
child frequently complains of headache and dizziness. Often 
he stumbles when walking. A sharp cry at night without 
waking is common. In young children with an open fontanel, 
this is found to be tense and bulging. Older children are apt 
to show changes in the eyes, which are often crossed, and show 
a rapid side-to-side motion. As the disease progresses, con¬ 
vulsions become common, the child is drowsy, and there is 
muscular rigidity with drawing back of the head. Digestive 
symptoms are usually pronounced, the vomiting and failure 
to take food producing marked emaciation with a particularly 
noticeable sinking in of the abdomen. The respirations be¬ 
come irregular, often of the Cheyne-Stokes type. This consists 
of periods of deep breathing followed by periods of quiet. 

After a time the patient’s drowsiness increases to coma, and 
for days he may lie unable to recognize his parents or to take 
nourishment. He sinks rapidly, and death follows from ex¬ 
haustion or in convulsions. 

Prognosis.— As the diagnosis of tuberculous meningitis is 
sometimes very difficult, the outlook should always be given 
guardedly. Once the tubercle bacillus is found in the spinal 
fluid, however, the outlook is hopeless. 

Treatment.— There is no specific treatment for tubercu¬ 
lous meningitis, all that can be done is to make the patient as 
comfortable as possible. 

Other Forms of Meningitis 

Other bacteria than those mentioned may cause meningitis, 
the more common being the pnuemococcus and influenza bacil¬ 
lus. These forms occur as a rule with pneumonia and influenza 
which aids in their recognition. On lumbar puncture the or¬ 
ganisms are found in the spinal fluid and the diagnosis con¬ 
firmed. There is no specific treatment for any of these types 
of meningitis, and they are usually rapidly fatal. 


INFECTIOUS DISEASES 


i77 


INFANTILE PARALYSIS 

Synonyms. —Acute Poliomyelitis, Acute Anterior Poliomye¬ 
litis. 

Etiology. —Poliomyelitis is transmitted by an organism so 
small that it will pass through the pores of a filter. These little 
bodies can be grown from the nose of patients with the disease, 
frequently also from those in contact with the patient, and 
occasionally from the nose of healthy carriers. In addition to 
scattered cases, there are widespread epidemics which sweep 
over the whole country. These epidemics occur in summer, 
usually being at their height in August. Children up to three 
years are most frequently attacked, although no age is exempt. 

Incubation Period. —This is usually ten days, although it 
may vary greatly. 

Symptoms.— The virus may attack any part of the brain 
or spinal cord, the location and the degree of paralysis de¬ 
pending upon the point of this attack and its severity. With 
all of the various types, however, there are found the same 
general symptoms. The onset is usually sudden with vomiting 
and occasionally convulsions. The child becomes drowsy and 
irritable and it is noticed that he has fever. After a few hours 
he begins to complain of headache, stiff neck, and pains in the 
arms and legs. The fever subsides after two or three days, 
and then it is noticed that the child is unable to walk, or that 
he has lost the use of his arms, or that his facial muscles do not 
function properly. The paralyses may spread somewhat for a 
few days, then usually remain stationary for a week or more. 
Then as a rule there is gradual recovery in some of the affected 
limbs, which goes on for about six months. At the end of that 
time what paralysis remains is usually permanent. When 
certain parts of the central nervous system are attacked, the 
muscles which control swallowing and breathing are paralyzed. 
In these cases the patient frequently dies from inability to 


178 TEXTBOOK OF PEDIATRICS FOR NURSES 

breathe. On the other hand, there are many mild cases which 
have the initial symptoms which may have slight paralyses, 
and which can be proved by examination of the spinal fluid to 
be true poliomyelitis, in which complete recovery takes place. 
Between these two extremes lie the children who survive, but 
who must go through life with legs or arms withered, drawn 
out of shape and useless. 

Prognosis. —The outlook for life is good except in those 
cases which involve the vital centers. In paralyzed cases one 
can always look for some improvement. But in many cases 
there is permanent and disabling damage to the legs or arms. 

Treatment.— The patient should be carefully isolated and 
all secretions burned. He should be kept as quiet as possible. 
Deformities are sometimes lessened by putting the legs in plas¬ 
ter casts. Pain in the extremities sometimes calls for the use 
of drugs such as morphin. After the acute stage is passed, 
massage and passive motion is to be employed to prevent as 
far as .possible atrophy of the muscles while the process of 
nerve repair is going on. When the recovery has progressed as 
far as it will by these means, recourse must be had to surgery 
to correct still further the paralyses and deformities. 

Quarantine .—The patient should be isolated for at least six 
weeks. 


CHAPTER XVI 
RESPIRATORY DISEASES 











CHAPTER XVI 


RESPIRATORY DISEASES 

ADENOIDS 

The subject of adenoids is an important one for the school 
nurse and those engaged in public health work among children. 
Often it is the nurse who recognizes the condition and takes the 
patient to the physician. When we say that a child has ade¬ 
noids we mean that the lymphoid tissue normally present in 
the upper part of the pharynx has become so overgrown as to 
cause difficulty in breathing, or impairment of hearing or 
frequent colds. 

Etiology. —Adenoids are most common in children from 
three to ten years, although they may occur in infants and in 
older children. Children with rickets and fat flabby children 
are more susceptible than properly fed children. Attacks of 
cold in the head and measles frequently bring about the enlarge¬ 
ment. In consequence they are more apt to be noticed in winter 
or spring than at other times, because then they are enlarged 
by frequent colds. 

Symptoms. —Obstruction of the pharynx so that nasal 
breathing is interfered with furnishes the most definite symp¬ 
toms of adenoids. The child, unable to breathe well through 
the nose, keeps his mouth open. At night the mouth tends to 
shut, and the child tosses restlessly in the attempt to get suffi¬ 
cient air. He frequently snores. Deformities of the face and 
chest result from this obstruction. The nose becomes broad 
and flattened, the roof of the mouth becomes highly arched 
and narrow, causing crowding of the teeth with frequently 

181 


182 TEXTBOOK OF PEDIATRICS FOR NURSES 


protrusion of the upper incisors. All of this gives the child a 
dull and stupid look. It is spoken of as the “adenoid facies.” 
Changes in the chest are equally important. Difficulty in the 
entrance of air into the lungs when the chest expands results 
in pulling in of the ribs with each breath. The outcome is a 
pigeon-breast, a funnel-breast, or a deep groove around the 
chest corresponding to the attachment of the diaphragm. Ade¬ 
noids easily become infected, leading to frequent colds which 
are notable for the large amount of nasal discharge. Otitis 
media is also a common complication of adenoids, and repeated 
attacks always indicate the need for their removal. 

Treatment. —Medical treatment is merely palliative and 
should be used only until such time as the adenoids can be 
removed. Albolene may be used in the nose, 5 to 10 drops 
in each nostril before meals and at bedtime. In older children 
the addition of a little camphor and menthol is helpful. A 10 
per cent solution of argyrol in glycerin may be used in the 
nose once or twice a day if there is a purulent discharge. 

Removal of the adenoids is the ultimate treatment. This 
operation is attended with remarkably little discomfort to the 
patient. Usually he may leave the hospital within a few 
hours, and inside of three or four days has entirely recovered. 
Occasionally they return even when skillfully removed and a 
second operation is necessary. 

TONSILS 

The function of the tonsils is still an open question. The 
many deep crypts with which they are studded gives them a 
large surface area, and it does not seem improbable that this 
surface acts to gather germs from the pharynx and mouth, 
thus preventing their further progress. Certainly the tonsils 
are much exposed to bacterial attacks and frequently become 
infected. They are the site of infection in scarlet fever and 
usually in diphtheria. In addition they may show other forms 
of acute disease, and chronic enlargement. 


RESPIRATORY DISEASES 


183 


Septic Sore-throat 

Synonym. —Streptococcus Tonsillitis. 

Etiology.— As the name implies this disease is caused by the 
streptococcus. It occurs in epidemics which may be milk-borne 
or may be transmitted from person to person. It is more com¬ 
mon in the cold months. It is probable that one attack confers 
immunity. 

Symptoms. —The onset is usually sudden with a chill or, in 
younger patients, often a convulsion. The patient frequently 
complains of a sore-throat and there is headache, and soreness 
of the back and limbs. Usually there is vomiting. The tem¬ 
perature rises quickly to 104° F. or higher, and usually remains 
elevated for three or four days. On examining the throat, 
the tonsils are seen to be swollen, deep red, and covered in 
places with a grayish membrane. Enlargement of the glands 
of the neck occurs in practically all cases. The appearance of 
the throat often closely resembles diphtheria, from which it can 
only be told by cultures. Often there are scattered reddish 
spots over the body, which, with the throat, give a picture diffi¬ 
cult to distinguish from scarlet fever. 

Complications. —Otitis media is the most common complica¬ 
tion, while peritonitis and involvement of the heart are the 
serious ones. 

Prognosis.— Most cases in previously healthy children do 
well. Where the disease comes on in the course of another ill¬ 
ness, however, complications are more apt to set in, and the pa¬ 
tient to do badly. 

Treatment. —The patient should be rigidly isolated. He 
should be kept in bed and given a liquid diet. An ice-cap to 
the head and an ice-collar about the neck often make the patient 
more comfortable. The mouth should be carefully cleansed 
after taking food, and some mild watery spray used in nose 
and throat. The bowels should be kept open by means of mild 
laxatives or enemas. Phenacetin or aspirin are of benefit in 


ig 4 TEXTBOOK OF PEDIATRICS FOR NURSES 

lessening the muscle pains and general discomfort. The ears 
and heart should be closely watched in every case. 

Follicular Tonsillitis 

This is by far the most common form of tonsillitis, and it is 
one which susceptible individuals may have year after year, 
even several times a winter. 

Etiology. —The disease may occur in children of any age 
although it is not common before the third year. Children 
with adenoids and fat flabby children are more susceptible 
than those of firmer tone. One attack predisposes to another, 
and as each attack causes some increase in the size of the 
tonsils, children with large ragged tonsils are particularly sub¬ 
ject to the disease. The attacks are much more common in the 
winter months. Frequently the disease seems to be brought on 
by constipation or some indiscretion in diet. 

Symptoms. —The onset is usually fairly abrupt with chilly 
sensations and pain in the head and back. Frequently there is 
vomiting. Older children usually complain of pain on swallow¬ 
ing, while children up to four years often give no evidence of 
pain in the throat, but complain of “stomach ache,” putting the 
hand over the upper abdomen. The temperature rises rapidly, 
frequently reaching 104° or 105 0 F. the first evening. The face 
is usually quite flushed. It is characteristic of the disease that 
the temperature is out of all proportion to the degree of pros¬ 
tration, the patient often playing cheerfully in his bed with a 
temperature over 103° F. Examination shows the reddened 
and swollen tonsils to be studded with small grayish spots, 
slightly larger than the head of a pin. These are plugs of pus 
showing in the mouths of the tonsillar crypts. Often the 
glands at the angle of the jaw are swollen and tender. The 
disease usually lasts for four or five days. For the first 
two days the general pains are quite marked, and the tem¬ 
perature elevated especially in the afternoon. By the fourth 


RESPIRATORY DISEASES 


185 

morning the temperature is usually subnormal, although it may 
rise to ioi° F. in the afternoon, and the patient is free from 
discomfort. Convalescence is usually rapid. 

Complications.— Usually recovery is complete and unevent¬ 
ful. In rare cases the disease seems to be a forerunner of 
rheumatism and endocarditis. 

Treatment. —The patient should be in bed. During the 
first two days the diet should consist largely of fluids, and as 
much water as possible should be given. If there is constipa¬ 
tion or much vomiting an enema should be given. Older chil¬ 
dren may have the tonsils swabbed with argyrol or some other 
antiseptic solution, or the tonsils may be sprayed with Dobell’s 
solution. Younger children frequently resist these measures, 
and one must be content to drop a few drops of argyrol in the 
nostrils. Many children enjoy an ice-collar, and its use should 
be limited to children who do like it. The general discomfort 
is best relieved with phenacetin or antipyrin, while during the 
height of the fever the patient is frequently made more com¬ 
fortable by cool cloths to the head and frequent sponging of 
the face and hands with cool water or water and alcohol. 

Hypertrophied Tonsils 

As the result of frequent attacks of tonsillitis, many children 
develop chronically enlarged tonsils. These are of all grades, 
from those only slightly above the normal to great masses 
of tissue which meet in the midline and make swallowing all 
but impossible. Such tonsils are almost always associated with 
large adenoid growths. 

Etiology. —Large tonsils usually result from frequent at¬ 
tacks of tonsillitis. They are found particularly in school 
children in the lower grades. 

Symptoms. —Except in the case of the very much enlarged 
tonsils which interfere with breathing and swallowing, there 
are few symptoms due to the enlargement alone. However, 


186 TEXTBOOK OF PEDIATRICS FOR NURSES 

such tonsils are easily infected, and the child may lose much 
time from school due to repeated attacks of acute tonsillitis. 
Usually there are enlarged cervical glands associated with the 
enlarged tonsils. 

Treatment. —Medical treatment is of little or no avail in re¬ 
ducing the size of tonsils which have long been enlarged. Sur¬ 
gical treatment which consists in the removal of the tonsils, 
on the other hand, is frequently overdone. No operation which 
necessitates giving a child a general anesthetic should ever 
be entered upon lightly. Unless it is felt that the tonsils are 
a definite detriment to health, or are a constant danger, as in 
children who are subject to attacks of rheumatism, they should 
not be removed. 

OTITIS MEDIA 

Otitis media, usually translated by the child as “earache,” is 
one of the very common ailments of childhood. It consists 
in inflammation of the middle ear usually following some dis¬ 
ease in the nose or pharynx. It may subside spontaneously or 
the drum may rupture, permitting mucus or pus to flow out, 
and causing what is commonly known as a “running ear.” 

Etiology. —Otitis media is a bacterial disease which may be 
caused by any one of a number of organisms. As it is usually 
secondary to some disease of the nose or throat, the offending 
organism is often that which caused the underlying condition. 
Cold in the head, influenza, measles, scarlet fever, and pneu¬ 
monia are the conditions most frequently complicated by otitis. 
Children who have much adenoid tissue are most frequently 
attacked. Poorly nourished, sickly children, particularly those 
in institutions, are particularly apt to have the disease, and 
in these it may come on without any previous infection of the 
nose or throat having been noticed. 

Symptoms. —Earache, fever, and deafness frequently make 
the diagnosis in older children perfectly evident. In infants, 
however, otitis media is a frequent cause of obscure and even 


RESPIRATORY DISEASES 


187 

alarming symptoms. Children over two years of age usually 
localize the pain definitely, frequently holding the hand to the 
ear and resenting any attempt to examine it. In cases of scarlet 
fever, involvement of the ear may cause no pain and so may 
be overlooked unless the ears are regularly examined. Infants, 
on the other hand, seldom localize their pain correctly, fre¬ 
quently putting the fingers in the mouth, or pulling at the hair 
at the base of the skull. 

Fever is practically always present, and may go as high as 
104° or 105° F. It usually varies widely and may continue for 
days. If the drum ruptures or is incised, both the pain and 
the temperature subside rapidly. Deafness is usually present 
to a greater or less degree, but except in cases following scarlet 
fever it is seldom permanent. 

In addition to these obvious symptoms, one may see changes 
in the ear drum with an otoscope. Often there is redness about 
the edge of the drum which spreads over the surface as the con¬ 
dition becomes worse. Then, as mucus or pus collects in the 
middle ear, the drum can be seen to bulge from the pressure. 
Finally if the drum breaks the canal is seen to be full of dis¬ 
charge and, when this is swabbed out, pus may be seen throb¬ 
bing through an opening of the drum. 

Complications. —Mastoiditis, even though it is the most fre¬ 
quent complication, is still quite uncommon. Other complica¬ 
tions such as meningitis are very rare. 

Treatment. —In the milder cases a few drops of carbolated 
glycerin 10 per cent dropped warm into the ear will frequently 
give relief. Where the pain persists, and there is bulging of 
the drum or tenderness over the mastoid region, medical meas¬ 
ures are insufficient and the drum should be incised. This 
operation is occasionally performed under a general anesthetic, 
but as the patient is usually suffering from a respiratory in¬ 
fection a local anesthetic, such as cocain 4 per cent painted 
over the drum, is safer. The patient should be securely 
wrapped and firmly held while the physician performs the oper- 


188 TEXTBOOK OF PEDIATRICS FOR NURSES 


ation. Following the incision there is usually a flow of blood or 
pus from the canal, although in early cases the drum may heal 
with no discharge. After-treatment consists in keeping the 
canal clear by syringing. Usually it is sufficient to syringe the 
ear three times a day, although in cases with much thick 
purulent discharge more frequent cleansing is necessary. 
Warm boric acid or bichlorid of mercury, i : 10,000, are usually 



Fig. 17.— Examination of the Ears. Thus wrapped, and in this position, 
the child can be firmly held by one nurse. 


used. The syringing should be continued until the fluid comes 
away clear. Usually this requires three or four ounces of fluid. 
Following the syringing, the outer ear should be carefully dried 
and anointed with vaselin to protect the skin from macera¬ 
tion. Sometimes, after the canal has been cleansed, stronger 
antiseptics such as , mercurochrome or gentian-violet are 
dropped into the ear. 

Isolation .—Cases of otitis media following scarlet fever or 
measles should be isolated as long as there is any discharge, 
as this discharge may spread the disease. 





RESPIRATORY DISEASES 

CROUP 


189 


Catarrhal spasm of the larynx popularly known as croup 
is a fairly common disease of childhood. It is not to be con¬ 
fused with membranous croup which is the term sometimes 
used for diphtheria. 

Etiology. —Croup is a disease of young children, to which 
those of some families only are susceptible. Children with 
adenoids and large tonsils are particularly apt to be affected. It 
occurs usually in winter and early spring, particularly in cold 
weather. 

Symptoms. —The child comes in from play in the afternoon 
with a slight cough and running nose. Toward bedtime the 
cough becomes harsh and the voice may be hoarse. After a 
few hours of sleep, the child awakes in great distress. Breath¬ 
ing is difficult, and each inspiration noisy. The voice is usually 
reduced to a hoarse whisper, and the cough is harsh and 
metallic. The temperature may be slightly elevated and the 
pulse is rapid. To one seeing it for the first time the picture is 
an alarming one, and the terror of the parents is usually re¬ 
flected by increased excitement on the part of the patient. 

The paroxysm usually lasts for two or three hours after 
which the child goes off to sleep. He wakes in the morning 
with a harsh cough, but well enough to be up and around. 
Unless warded off by proper treatment the attack returns on the 
second and third night. 

Treatment. —This divides itself into two parts: treatment of 
the night attack, and prevention of a repetition on the succeed¬ 
ing nights. 

When one has assured himself that the condition is not 
laryngeal diphtheria, the first thing to do is to reassure and 
quiet the family. Peaceful surroundings at once produce im¬ 
provement in the patient. Of all the remedies in vogue for 
croup, the two which offer the most chance of success are steam 
inhalations and the production of vomiting. The child should 


190 TEXTBOOK OF PEDIATRICS FOR NURSES 

first be put in a croup tent filled with steam. If this fails to 
lessen the stridor he should be made to vomit by the use of 
full doses of syrup of ipecac. For a child of three or four 
years a teaspoonful may be given every fifteen minutes till the 
child vomits freely. Vomiting usually relieves the spasm, and 
the child goes back to sleep. Very rarely all these methods 
fail, and one must resort to intubation to prevent suffocation. 

The second phase of the treatment consists in the prevention 
of a recurrence. The child should be kept in the house in a 
comfortably warm room free from drafts. If he is consti¬ 
pated an enema should be given. During the afternoon the 
patient may receive alternately antipyrin and small doses 
of syrup of ipecac, one being given each hour. This method 
used on the second and third days seldom fails to prevent a 
paroxysm during the night. 

Prognosis.— Recovery is rapid and complete, but one attack 
predisposes to others. 


CHAPTER XVII 

RESPIRATORY DISEASES —Continued 
















CHAPTER XVII 


RESPIRATORY DISEASES ( Continued) 

BRONCHITIS 

Bronchitis is a common disease of infancy and childhood. 
It occurs in all degrees from mild attacks which last but a few 
days to serious conditions which can scarcely be told from 
bronchopneumonia and which persist for weeks. It is to the 
winter what diarrhea is to the summer. 

Etiology. —The disease may come on following exposure to 
wet and cold, or it may develop as a complication in colds, 
measles, influenza and other diseases. Certain children seem 
to have sensitive mucous membranes which make them suscep¬ 
tible to bronchial infections. Rachitic children and those in 
whom tonsils and adenoids are present are also unusually prone 
to attacks. Cold wet weather is a frequent inciting factor. 

Symptoms. —These depend largely upon the age of the pa¬ 
tient and the severity of the attack. In infants there are cough, 
increased rate of respiration and fever, depending in degree 
on the nature of the attack. Frequently one can hear and 
feel the mucus bubbling up and down in the larger tubes. 
What mucus is coughed up into the pharynx is promptly swal¬ 
lowed. This produces loss of appetite and sometimes vomiting. 
The mucus is frequently present in large quantities in the stools. 
When the chest is examined with a stethoscope the mucus can 
be clearly heard crackling or bubbling in the bronchi. These 
sounds known as rales are of value in determining the extent 
and progress of the disease. 

In older children there is usually pain over the front of the 

193 


194 TEXTBOOK OF PEDIATRICS FOR NURSES 

chest. The cough is persistent and may be worse at night. 
At first the cough is harsh and tight, later it becomes loose and 
productive, and children over six can usually be taught to ex¬ 
pectorate. In older children the fever is usually not marked, 
and subsides after a day or two. The cough may clear up in a 
week or ten days, or it may drag on till warm weather sets in. 

Prognosis.— In infants the disease may be a serious one, 
frequently merging without any definite changes into broncho- 



Fig. 18.— Inhalation. A canvas covering fits closely about the crib. 

Croup kettle is heated by electric hot plate. 

pneumonia. Particularly is this true when the disease follows 
measles or influenza. In older children recovery is usually 
prompt, although frequent attacks may gradually wear a child 
down and interfere seriously with his attendance at school. 

Treatment.— If there is fever the child should be in bed, at 
any rate he should be indoors in a warm well-ventilated room, 
out of drafts. The diet should be light while there is fever 
or gastro-intestinal symptoms, but care should be taken that the 
general nutrition of the child suffers as little as possible. Little 
can be done by local applications although a mustard plaster 








RESPIRATORY DISEASES 


195 

to the chest sometimes seems useful in infants. Certainly the 
popular practice of anointing the child with goose grease or 
other oily substances and applying layers of flannel cannot be 
too strongly condemned. Inhalations of steam which may be 
medicated as with compound tincture of benzoin are of un¬ 
doubted value, especially in the early stages of the disease when 
the cough is dry and painful. Cough syrups are often helpful, 
but it must be remembered that they all affect the appetite 
unfavorably, so that they must be used sparingly. Paregoric 
or codein is often needed for the first few nights in order that 
the patient may get some rest. Adrenalin, administered hypo¬ 
dermically, is necessary in the rare cases in which asthmatic 
attacks occur in the course of the bronchitis. Children who 
have rickets as an underlying condition should, of course, re¬ 
ceive cod-liver oil. Children who have repeated attacks are 
so completely incapacitated thereby that every effort should be 
made to have them spend the winter months in some mild 
climate. 

PNEUMONIA 

Classification. —In adult medicine, pneumonias are usually 
divided under two heads, lobar pneumonia and bronchopneu¬ 
monia. In the first, as the name suggests, the disease is largely 
confined to one or sometimes more lobes of the lungs, which 
lobes are usually attacked in their entirety, while the remaining 
lobes are clear. In bronchopneumonia, on the other hand, 
the process is a scattered one, attacking small patches through¬ 
out all the lobes. This distinction is based, it can be seen, on 
the anatomy and pathology of the disease. 

Both types of pneumonia are found also in children, but 
with them it is far better to classify the diseases clinically than 
pathologically. From this standpoint one separates the cases 
in which pneumonia is the initial and only disease from those 
cases in which pneumonia comes on in the course of another 
disease. The first is spoken of as primary pneumonia, the 


196 TEXTBOOK OF PEDIATRICS FOR NURSES 

other as secondary pneumonia. They are so different in their 
course and outcome that they deserve to be discussed separately. 

Primary Pneumonia 

Primary pneumonia is that type which comes on suddenly 
in previously well children. 

Etiology. —The disease is usually caused by the pneumococ¬ 
cus, although occasionally the influenza bacillus or other or¬ 
ganisms may be responsible. As it is most prevalent in the 
winter and early spring, exposure to cold and wet seems to play 
a part in its production. It may attack children of any age, 
but robust children from two to ten years seem most often 
affected. 

Symptoms. —The onset is usually sudden, with chilly sensa¬ 
tions, frequently vomiting, and in infants sometimes convul¬ 
sions. Within a short time the child is obviously ill and is 
willing to stay in bed. The breathing, even at this early stage, 
is characteristic. It is shallow, largely abdominal, and rapid, 
often reaching 80 a minute. At first, it seems effortless, but 
later in the course of the disease, particularly if the patient is 
doing badly, the breathing may become deeper and labored, 
the whole chest coming into play. As a rule,, the nasal openings 
widen with each breath, this dilatation of the alae nasi being 
quite characteristic of the disease. Also with each expiration 
there is often a quick grunt. Both of these symptoms occa¬ 
sionally occur in children with a high fever from some other 
cause and so must not by themselves be interpreted as meaning 
pneumonia. Cough is not a marked symptom, often being en¬ 
tirely absent. When present it is usually unproductive, unlike 
the abundant rusty, blood-stained sputum of the adult. Pain 
sometimes is severe, but more often it is moderate or slight. 
It is usually poorly localized, often being referred to the ab¬ 
domen. In fact, it is not an unheard of thing for a child with 
a beginning pneumonia to be operated upon under the impres- 


RESPIRATORY DISEASES 


197 

sion that he is suffering from appendicitis. The temperature 
usually rises during the first few hours to 103° F., or more, 
and frequently continues at that level throughout the disease 



Fig. 19.—Temperature Chart of Primary Pneumonia. Crisis on the 
eighth day. 

In less typical cases it may vary daily through a wide range. 
The pulse is rapid from the start, often reaching 150 or more 
per minute. Counting so rapid a pulse is almost impossible for 
the nurse to do accurately, but fortunately the quality is of 
more importance than the rate, and even with a rapid pulse 





























































198 TEXTBOOK OF PEDIATRICS FOR NURSES 

one can determine whether it is full or thready, regular or 
otherwise. The course of the disease may vary with the child 
and the attacking organism, but generally after the tempera¬ 
ture has been elevated for about a week there comes a sudden 
change in the patient’s appearance. The breathing becomes 
less rapid and more nearly normal in character, the patient, 
while still weak, loses his ill look. He feels better and fre¬ 
quently settles himself for the first quiet, natural sleep which 
he has had in days. This remarkable change is accompanied by 
a drop in temperature from 103° F. or higher to normal in the 
space of a few hours. Such a rapid termination of the disease 
is spoken of as the crisis. Usually when the temperature comes 
down by crisis it stays at or near normal, although occasionally 
there are rises on two or three succeeding days to 100 or 
ioi° F. In some instances, particularly with younger children, 
the disease ends by lysis, that is, instead of an abrupt termina¬ 
tion, the temperature falls gradually, each day reaching a 
slightly lower level, until after days or sometimes weeks it 
reaches normal. Such a termination is more common in sec¬ 
ondary pneumonia and is never as favorable as a crisis. 

Complications. —Empyema occurs occasionally during or fol¬ 
lowing primary pneumonia. It consists of a collection of pus 
within the pleural cavity. The treatment is surgical and 
consists in draining the pus off through an opening in the chest 
made by removing a section of rib. Following such an opera¬ 
tion the wound usually drains for ten days or more and the 
most careful dressing and nursing is necessary to prevent ab¬ 
scesses and bed sores. Otitis media is a more frequent but far 
less formidable complication. The comfort of the patient 
usually require that the drum be incised when this condition is 
found. 

Prognosis. —The outlook in a given case depends upon the 
age of the patient, his general state of health, and the extent 
of the disease. Children over two years of age recover in the 
vast majority of cases. Under two the chances are in favor 


RESPIRATORY DISEASES 


199 

of the child but decrease the younger he is. Continued high 
fever and marked nervous symptoms, particularly convulsions, 
are bad omens. 

Treatment. —As yet there is no satisfactory specific treat¬ 
ment for pneumonia, and our energies must be directed 
toward making the patient comfortable, avoiding complica¬ 
tions so far as possible, and treating them should they arise. 

The patient should be in a comfortable bed, in a large well- 
ventilated room, free from drafts. He should be in a loose 
warm gown, unhampered by heavy or constricting jackets, 
pads, or poultices. The diet should be largely liquids, and 
should be offered at regular intervals. Pain in the chest can 
often be relieved by an ice-bag, although frequently codein 
or morphin is required. Unless the temperature goes unusually 
high, no treatment is necessary to bring it down. If a tempera¬ 
ture of over 104° F. is associated with marked restlessness or 
delirium, cool moist cloths to the head or a tepid sponge bath 
may be quieting. There is seldom any indication for stimu¬ 
lants in these cases. When signs of cardiac or respiratory fail¬ 
ure do occur, however, energetic stimulation is indicated. 
These signs of collapse will be dealt with under Secondary 
Pneumonia, in which condition they are far more common. 

Special care should be taken to keep the mouth clean and 
the nose free from purulent discharges. The abdomen must 
be carefully watched, as tympanites by causing pressure 
upward against the diaphragm embarrasses both heart and 
lungs. The tympanites may sometimes be relieved by the use 
of a hot water bag over the abdomen. More often, however, 
one must resort to a rectal tube. In delirious or stuporous 
patients the bladder must be carefully watched and if it be¬ 
comes distended this fact should be brought to the physician’s 
attention. Convalescence is usually rapid and the usual 
methods of rest and careful feeding are all that are necessary 
to bring the patient back to complete health and strength. 


200 TEXTBOOK OF PEDIATRICS FOR NURSES 


Secondary Pneumonia 

Etiology. —As the name implies, secondary pneumonia fol¬ 
lows some other disease, especially those which involve the 
respiratory system. It is most common following measles, 
whooping-cough, influenza, bronchitis and diphtheria, although 
it may occur in children debilitated by prolonged intestinal up¬ 
sets. While it attacks children of any age, those under three 



Fig. 20.—Temperature Chart of Secondary Pneumonia Following 
Measles. Patient was a boy 16 months old. Temperature fell by lysis. 


years of age are most frequently affected. It is especially 
common and virulent in orphanages and foundling asylums. 
It is almost always of the widespread or bronchopneumonic 
type and may be caused by any one of a number of organisms. 

Symptoms. —The onset is usually indefinite, merging inti¬ 
mately with the preceding disease. There are no special symp¬ 
toms of onset as with the primary form. In a child with 
measles, for example, the looked-for drop in temperature does 
not occur, and the cough, instead of improving, becomes more 
















































































































RESPIRATORY DISEASES 201 

troublesome. After a day or so, definite signs may appear in 
the chest and one realizes that pneumonia has developed. The 
breathing is rapid, 


is 

frequently ioo to the 
minute, and is la¬ 
bored. Usually there 
is dilatation of the 
ahe nasi. Cough is 
much more trouble¬ 
some than in cases of 
primary pneumonia. 
Pain is usually not 
marked. The tem¬ 
perature is usually 
neither as high nor as 
constant as in the 
primary form. Pros¬ 
tration is generally 
very great and pro¬ 
gresses as the disease 
continues. The course 
of the disease is very 
indefinite, sometimes 
terminating in a few 
days, more often 
dragging on for two 
weeks or more. In 
favorable cases, the 
temperature then 
gradually falls, 
each day approaching 
more nearly to 


Day of 
Disease 

Temp. 

109 

108 

107 


106 


105 


104 


103 


102 


101 


100 


99 


98 



Fig. 21.—Temperature Chart of Secondary 
Pneumonia Following Whooping Cough. 
This was the same boy whose chart is shown 
in Fig. 20. At 20 months he developed 
whooping cough. Two weeks later pneu¬ 
monia developed. Death on the sixth day. 

normal, till after days it finally becomes constant at normal. 

Relapses are common and all too frequently the temperature 

will fall for a few days, then there will be an extension of the 























































202 TEXTBOOK OF PEDIATRICS FOR NURSES 


disease and it will go back to the old high level. In many 
of these protracted cases the patient’s strength finally gives out 
and he dies of exhaustion. 

Sometimes even in cases of short duration where the toxemia 
is very great, the patient may develop signs of collapse of the 
circulation or of respiration. Sudden weakness, with a rapid 
irregular pulse, and cold extremities point to cardiac failure. 
Cyanosis and loud rales in the throat with increased labored 
respiration indicate respiratory failure. Such changes call for 
prompt action, and should be reported to the physician at once. 

Complications.— Secondary pneumonia has a decided ten¬ 
dency to become chronic, with permanent changes in the lungs 
which serve as a starting place for fresh attacks with any future 
exposure. Otitis media is common and should always be 
watched for. Ulceration of the mouth and sores about the 
nose and lips will develop unless most careful attention is paid 
to cleanliness of these parts. 

Prognosis. —The outlook in secondary pneumonia is always 
grave, nearly one half of all the patients succumbing. 

Treatment. —Older children should be in bed. Infants are 
sometimes benefited by the change in position that comes when 
held in the nurse’s arms. As the disease is apt to be of long 
duration, great care must be taken to maintain the nutrition 
at the highest possible point. Simple, nourishing food should 
be given at regular intervals when the patient is strong enough 
to take it. Liquids must, of course, form the major part of 
the diet in younger patients. 

The cough is sometimes made easier by inhalations, but 
often some drug such as codein is necessary if the child is 
to get any rest. 

Stimulants are often needed in cases of collapse; of these 
adrenalin and caffein have the most prompt action, while digi¬ 
talis is the most useful as a cardiac stimulant over a longer 
period. Oxygen is sometimes used in cases of cyanosis. 


CHAPTER XVIII 

TUBERCULOSIS AND SYPHILIS 















CHAPTER XVIII 


TUBERCULOSIS AND SYPHILIS 

TUBERCULOSIS 

Tuberculosis is more widespread and more varied in its 
manifestations than any other disease. It takes on as many 
different forms as there are organs in the body. 

Etiology. —Two forms of tubercle bacillus are met with in 
man: the human, and, more rarely, the bovine type. Children 
acquire the former by association with persons ill with tuber¬ 
culosis, the latter from the milk of tuberculous cows. Certain 
diseases make the child particularly susceptible to infection. 
Thus it frequently follows measles or whooping-cough. Babies 
are seldom born with the disease, but children of tuberculous 
parents frequently acquire it at an early age. 

The Tuberculin Test. —There are various tests which can be 
used to show the presence of infection with the tubercle bacil¬ 
lus. Of these the most used with children are the Pirquet 
test and the intracutaneons test. In the former, a preparation 
made from the tubercle bacillus, known as “tuberculin,” is 
applied to a superficial scratch on the skin. In the latter, a 
measured amount of tuberculin is injected into the skin. In 
either case a reaction takes place about the site of the test, 
in the course of from twenty-four to forty-eight hours, in 
children who have a tuberculous infection. When one of these 
tests is carried out on large numbers of children a surprisingly 
large percentage of positive reactions occur, many children who 
seem perfectly well showing a positive test. This necessitates 
dividing those who give a positive reaction into two groups, 

205 


206 textbook of pediatrics for nurses 


those who have a tuberculous infection, but no symptoms refer¬ 
able to the disease, and those who have symptoms caused by 
the disease. The former are said to have a tuberculous infec¬ 
tion, the latter have tuberculosis in one of its forms. 

Types of Tuberculosis.— In adults the pulmonary form of 
tuberculosis is by far the most oommon. In children, on the 
other hand, gland and bone tuberculosis are more common, 
while rapidly fatal forms such as miliary tuberculosis and 
tuberculous meningitis occur much more frequently than they 
do in adults. 

Tuberculosis of the Lymphatic Glands. —The glands of the 
neck and those at the root of the lung are most freauently en¬ 
larged, although any glands may be involved. These are asso¬ 
ciated with general symptoms such as fever, loss of appetite and 
loss of weight, and local symptoms due to pressure depending 
on the position of the glands. Thus enlarged glands around 
the root of the lungs may cause cough and changes in the voice. 
Cervical glands are particularly apt to break down and dis¬ 
charge. They differ from glands infected with other organ¬ 
isms in that they show but little tendency to heal, frequently 
discharging for months or years, and leaving as a rule ugly 
puckered scars. 

Tuberculosis of the Bones and Joints. —Bone and joint tu¬ 
berculosis are surgical conditions and are mentioned here only 
as illustrating the varied types of tuberculosis. They are ex¬ 
tremely chronic conditions and frequently result in marked de¬ 
formities. 

Miliary Tuberculosis. —In infants and young children tuber¬ 
culosis sometimes becomes scattered throughout the body. 
This is known as miliary tuberculosis. At first the only symp¬ 
toms may be fever, loss of appetite and loss of weight. The 
fever may not be high, but each afternoon there is an elevation 
perhaps to ioo° or ioi° F. The child gradually becomes weak 
and pale but it may be several weeks before there is anything 
definite to point to tuberculosis. Usually the first indication 


TUBERCULOSIS AND SYPHILIS 


207 


of the nature of the disease comes when the lungs are suffi¬ 
ciently involved to cause a cough, although sometimes menin¬ 
gitis develops, which on examination of the spinal fluid, proves 
to be tuberculous. The outlook in this form of the disease 
is very bad. 

Pulmonary Tuberculosis .—When the tubercle bacillus at¬ 
tacks the lungs, it may set up a bronchitis or a pneumonia just 
as other organisms do, and for a time it may be impossible to 
tell them apart clinically. When the condition persists, how¬ 
ever, after it should be clearing up if caused by any other or¬ 
ganism, one begins to suspect the real state of affairs. With 
the help of X-rays and the tuberculin test a definite diagnosis 
can usually be made. The outlook in pulmonary tuberculosis 
in children becomes better as the child becomes older. Under 
two years the prognosis is very bad. At any age prolonged rest 
in bed is necessary for a cure. 

Latent Tuberculosis .—This is by far the largest group of 
cases, and in many respects the most important. These are 
the children who, at some time, have become infected with 
tubercle bacilli, but in whom the infection was so slight or the 
resistance of the body so good that the infection has been over¬ 
come, usually with no recognized symptoms. These are the 
children who react to tuberculin without having any other 
signs of the disease, and most of them go through life with¬ 
out ever developing active symptoms. However, any prolonged 
illness, or any sudden loss of weight, may reduce their resist¬ 
ance to the point where the disease can become active. Measles 
and whooping-cough are particularly apt to cause a flare-up, 
and from these diseases this group of children should be most 
carefully guarded. They should lead an easy, carefree life, 
with plenty of sleep and rest, good food and fresh air. If 
they can be kept a few pounds over weight, and away from 
acute infections, their chances are excellent. 

Prophylaxis. —All children should be shielded as far as 
possible from tuberculosis. This means that they should be kept 


208 textbook of pediatrics for nurses 


away from persons who have the disease in an active form. 
An infant should not be nursed by its mother if she is tuber¬ 
culous. The child’s nurse should be free from the disease. 
Rooms where tuberculous persons have lived often become 
heavily infected, and one should always be careful to ascertain 
on moving into a new house or apartment that the former 
occupants were not actively tuberculous. To protect the child 
from the bovine form of the disease, the milk should be from 
tuberculin-tested cows or, failing this, it should be thoroughly 
boiled. 

Treatment. —The primary treatment in all forms of tubercu¬ 
losis is rest. The patient should be in bed until the temperature 
has stayed constantly at normal for a considerable length of 
time. Then he should be allowed up gradually, slowly increas¬ 
ing the amount he is allowed to do. On any rise of tempera¬ 
ture he should be returned to bed and kept there longer than 
would be the case with another child. The second requisite 
is good wholesome food. In older children it is far better 
to give three meals a day than to run the risk of destroying the 
appetite or ruining the digestion by trying to feed them between 
meals. The third item in treatment is fresh air. Wherever 
possible these children should live in the open, eating and 
sleeping out of doors. Sunshine is a great tonic, and the child 
should have as much of it as possible. Drugs are seldom of 
value but sometimes are necessary to allay pain or give the 
child rest from a troublesome cough. Injections of tuberculin 
are used in treating certain forms of the disease, particularly 
where the eyes are involved. This type of treatment unfortu¬ 
nately has not proven of value in the more widespread cases. 

SYPHILIS 

Syphilis in childhood is of two forms: the hereditary and 
the acquired, of which the former is by far the more common. 
Both are caused by the same organism, the spirochseta pallida. 


TUBERCULOSIS AND SYPHILIS 


209 


Acquired Syphilis 

Children are usually infected by being kissed by persons 
having active syphilitic lesions of the lips or mouth. In con¬ 
sequence the primary sore of the disease is usually on the mouth 
or face. Usually the infection takes place from a parent, more 
rarely from a nurse maid. Except that it is relatively more mild 
and responds more readily to treatment, acquired syphilis is 
similar to the hereditary form. 

Hereditary Syphilis 

Etiology. —A woman with active manifestations of syphilis 
usually transmits the disease to her unborn child. The result 
varies somewhat with the stage of the disease in the mother. 
Often there is an abortion in the early stages of pregnancy. 
Sometimes the infant is born prematurely and soon dies. 
When the pregnancy is of the usual duration the child may ap¬ 
pear in excellent condition at birth and the disease not be 
recognized till later. 

Symptoms. —If born at term the first symptoms are usually 
noticed when the child is from two to four weeks old. At 
first there is a coryza with much discharge and the formation of 
crusts in the nose. Often the discharge is bloody. The 
crusts give rise to nasal obstruction which causes “snuffles” 
which are very characteristic of the disease. Associated with 
the snuffles there is frequently hoarseness. Soon after the 
snuffles, a rash is seen on the face, arms and legs. This con¬ 
sists in bright red circular spots which later fade out, leaving 
a brownish stain. Occasionally there is scaling of the palms 
and soles. 

A very characteristic feature of the disease is the sores 
about the mouth and anus. At the corners of the mouth deep 
ulcers form which heal slowly, leaving deep scars. These 
scars contract, giving the mouth a puckered appearance. 


2io TEXTBOOK OF PEDIATRICS FOR NURSES 


Around the anus there often develop moist elevated patches 
of a pinkish color which are known as condylomata. These 
open sores of syphilis may contain the organisms of the dis¬ 
ease so that in handling an infant with such lesions the greatest 
care is necessary to prevent infection. 

Changes in the bones and joints occur which are often pain¬ 
ful. These occasionally give rise to a faulty diagnosis of 
paralysis as the child is disinclined to use the painful extremity. 
The teeth of the second set often give a late evidence of he¬ 
reditary syphilis. The most significant change is shown in the 
upper middle incisors. These are peg-shaped, tend to lean 
toward each other, and have a rounded notch in the lower edge. 
These are known as Hutchinson’s teeth. 

Wassermann Reaction .—This is a laboratory test for the 
detection of syphilis. It may be performed on the blood or on 
the spinal fluid. To carry out the test a few cubic centimeters 
of these fluids are needed which may be obtained by inserting 
a needle into a vein, or by lumbar puncture. In suspected 
cases, blood may be taken at birth from the umbilical cord be¬ 
fore it is tied. 

Prognosis.— This depends upon the severity of the infection 
and whether or not the patient was carried to term. Babies 
who are in good condition at birth may do well if treated ac¬ 
tively from the start. In syphilitic babies born before term 
the outlook is not good. Acquired syphilis usually does better 
under treatment than the hereditary form. 

Prophylaxis.— Syphilis is so much easier to prevent than to 
cure that every measure should be taken so that the infant 
may start life free from the disease. Persons with the dis¬ 
ease should, of course, not marry until a prolonged course of 
treatment has been carried out and the blood has been found 
to be negative. A syphilitic woman who becomes pregnant 
or a pregnant woman who becomes syphilitic should be ener¬ 
getically treated. This often is rewarded by the birth of a 
normal infant at term. Finally every precaution should be 


TUBERCULOSIS AND SYPHILIS 


211 


taken to prevent the infection of a normal child by syphilitic 
parent or nurse. On the other hand, a syphilitic infant should 
be allowed to nurse from no one but the mother, as a wet 
nurse may easily become infected from the sores in or about 
the mouth of a diseased child. 

Treatment.—When the diagnosis of syphilis is made, treat¬ 
ment should be at once begun. The usual treatment consists 
in a series of intravenous injections of salvarsan or one of 
the later modifications of that drug. Five or six injections are 
given at intervals of a week. Then there is a rest period and 
another series is given. The number of courses of injections 
depends on the progress of the disease and upon the Wasser- 
mann reaction which may be taken at the beginning of each 
course. Between injections some other form of treatment is 
usually used. With infants this is usually inunctions of mer¬ 
curial ointment, the so-called “blue ointment.” A pea-sized 
piece of the ointment is placed upon a piece of linen and laid 
on the abdomen under the band. This moves around as the 
baby twists and turns, thus effectually rubbing the ointment 
into the skin. Local sores are usually treated with calomel 
either as a powder or in an ointment. Special pains must 
be taken to clear the crusts from the nose and to apply ointment 
to ulcerated areas. This enables the child to breathe more 
easily and makes him more comfortable. 









CHAPTER XIX 


DISEASES OF THE SKIN 
















CHAPTER XIX 


DISEASES OF THE SKIN 

An infant's skin is very delicate. It is sensitive to irrita¬ 
tion and infection from without and to derangements within 
the body. There are certain children who will develop skin 
troubles in spite of the most painstaking care, but in the ma¬ 
jority of cases a reasonable amount of attention to cleanli¬ 
ness and avoidance of irritation will keep the skin in a healthy 
condition. 

Moisture is irritating to the infant’s skin. After his bath 
he must be dried with care. All the folds of the skin should 
be given especial attention. It is far better to dry the skin 
thoroughly than to leave it moist and trust to a coating of 
powder to absorb the excess moisture. When wet or soiled 
he must be cleansed, dried and fresh diapers applied. If he is 
drooling, as all babies do from the third to the sixth month, 
one must be careful lest the saliva irritate the chin, cheeks and 
neck. If irritation appears, a little lanolin or cold cream, ap¬ 
plied several times a day, will sometimes check it. Likewise 
cold and raw winds may set up irritation on the face and 
hands. In children who chap easily the hands should be cov¬ 
ered with mittens and a little cold cream applied to the cheeks 
before taking the child out in cold weather. If this is not 
sufficient, a veil may be worn. 

Where numbers of children are together, as in asylums or 
schools, the greatest care is necessary to prevent the spread of 
the common contagious skin diseases, so that a knowledge of 
these is very essential to the nurse. 

215 


216 textbook of pediatrics for nurses 


ECZEMA 

Etiology. —This is the most common skin disease of child¬ 
hood. It occurs at any age, although it usually has its be¬ 
ginning during the first six months. Children in certain fami¬ 
lies have a marked predisposition to eczema and develop it on 
the slightest provocation. Well-nourished children are more 
susceptible than poorly nourished. The disease is not con¬ 
tagious and is usually set up by some form of external irrita¬ 
tion. Cases which last after the second year usually depend 
in addition on sensitivity to certain foods, particularly egg. 
There are many forms of eczema, so that only the most com¬ 
mon manifestations can be set down here. 

Symptoms. —The disease usually starts on the face. The 
skin becomes thickened and scaly. Sometimes there is weep¬ 
ing with the formation of brownish crusts. These lesions itch, 
and if the child is not restrained he will scratch until bleeding 
takes place. Usually the disease does not confine itself to the 
face, but after a time spreads to the neck and trunk as well. 
In consequence of the itching the child is very restless and 
tosses constantly in his sleep. In older children it is more apt 
to attack the bend of the elbow and wrist and the back 
of the knee. In them the nervous reaction is usually not so 
great. 

Complications. —The danger of infection both local and gen¬ 
eral is the only common source of complications. 

Prognosis.— Eczema is a stubborn disease. Most cases oc- 
curing in infancy clear up by the time the child is a year and 
a half old. Before that time the disease can usually be held 
in check with appropriate treatment but not permanently cured. 

Treatment. —The first indication is to remove all sources of 
outside irritation. Careful inquiry must be made concerning 
the type of soap and powder used and the kind of clothing 
worn, and all possible errors corrected. In cases where the 


DISEASES OF THE SKIN 


217 


involvement is extensive the patient is often benefited by sub¬ 
stituting salt or bran baths for the usual soap and water. Then 
the diet should be gone into and carefully regulated. Many 
cases in breast-fed infants respond favorably if the interval 
between nursings is lengthened and the time of nursing de¬ 
creased. In artificially fed children the sugars in the formula 
are frequently at fault. Finally the disease should be treated 
locally by the use of salves and lotions. Many of the oint¬ 
ments on the market for eczema are too strong for the tender 



Fig. 22.—Splints for the Elbows. These are covered with canton flannel 
and have tapes conveniently arranged for tying. 

skin of the infant and tend to make matters worse rather than 
better, so that the choice of the preparation to be used must 
always be left to the physician. Often in bad cases of facial 
eczema it is necessary to apply some type of covering to keep 
the salve on. For this purpose a mask made of muslin with 
holes for the eyes and mouth, which can be held snugly in 
place, is valuable. Where the condition is made worse by 
scratching, some method of restraining the hands is necessary. 
Splints made of stiff cardboard covered with cloth and pro¬ 
vided with tapes so that they can be tied around the elbows are 
excellent where the eczema is of the face only. When other 





218 textbook of pediatrics for nurses 


parts of the body are involved it is sometimes necessary to 
fasten the arms to the sides either by pinning the sleeves to 
the diaper or by specially devised wristlets which may be fast¬ 
ened to the bed. 



Fig. 23.—Splints Applied. These are used to prevent scratching in 
eczema of the face. 


INTERTRIGO' 

This is a special form of eczema found most commonly in 
fat babies. It involves those areas where two skin surfaces 
rub together as in the folds of the neck and between the thighs. 
The skin becomes reddened, somewhat thickened and oozes a 
colorless sticky fluid. Itching and burning is intense and, 
when the napkin area is involved, each time the child voids 
he suffers severely. 

Treatment. —When in the folds of the neck, the condition 
can often be relieved by cutting crescents of old linen, much 






DISEASES OF THE SKIN 


219 


the shape of dress shields, rubbing them with fine cornstarch, 
and laying them between the inflamed surfaces. When the 
napkin area is involved, the problem is more difficult. In the 
first place the child must be kept clean and dry. It is usually 
necessary to change him several times during the night. No 
soap or water should be used in cleansing him, olive oil on soft 
cloths being substituted, except at his morning bath. Finally 
for an hour, morning and afternoon, he should be left without 
his diaper in a warm room, preferably lying on a pad in bed, 
so that the air can dry the affected area. Particularly stubborn 
cases may be treated with ultraviolet rays. 

SEBORRHEA 

The oily dirty-looking scales which frequently form on an 
infant’s scalp are due to seborrhea. While usually free from 
danger, the condition is unsightly and, if untreated, is apt to 
spread. A satisfactory treatment is to rub the scalp for three 
mornings with olive oil, on the fourth morning a thorough 
shampoo is given and the scales gently removed. The scalp 
is then carefully dried and a little sulphur ointment rubbed in. 
At the end of a week the whole treatment is carried out 
again. Usually three courses are necessary for a permanent 
cure. 


MILIARIA 

This disease is due to stoppage and irritation of the sweat 
glands. The most common form is generally known as 
“prickly heat’’ and is caused by hot weather or overclothing, par¬ 
ticularly where wool is used next to the skin. It consists of 
small bright red papules occurring in patches usually on the 
neck, over the chest and between the shoulders. It itches badly 
and this may lead to scratching and infection. 

Treatment. —This consists in light, non-irritating clothing, 


220 TEXTBOOK OF PEDIATRICS FOR NURSES 

frequent bathing with bicarbonate of soda solution, and pow¬ 
dering with stearate of zinc or starch. 

There is another form of miliaria which appears upon the 
cheeks and across the bridge of the nose in many infants at 
two or three months of age. It consists of scattered pinhead¬ 
sized whitish papules. Often these become inflamed and turn 
red. The condition is harmless but unsightly and can usually 
be relieved in a few days by gentle massage with cold cream. 

IMPETIGO CONTAGIOSA 

Impetigo is a bacterial disease of the skin. It is most com¬ 
mon in the poorly nourished and in institutions where it is 
highly contagious. The disease often starts from an infected 
burn or cut. The child picks at the crust which forms, getting 
the germs under the finger nails. Then wherever he scratches, 
the germs are deposited and new lesions develop. The lesions 
consist of vesicles filled with grayish fluid. These break and 
dry, leaving dirty brown crusts. After a time these crusts 
fall off, leaving no scars. The disease attacks only the outer 
layers of the skin as a rule, and the lesions are surrounded by 
little or no red area of inflammation. Sometimes, however, 
in poorly cared-for infants, deep infection takes place with the 
formation of ulcers or furuncles. The treatment, which works 
as though by magic, consists in applying white precipitate oint¬ 
ment, one-third standard strength. 

FURUNCULOSIS 

Furunculosis is often secondary to eczema, impetigo or mili¬ 
aria. It occurs most frequently in poorly nourished infants. 
The disease consists of pockets of pus which form under the 
skin, usually of the scalp, but in severe cases all over the body. 
The furuncles vary in size from the head of a pin to the size 
of a dime. The swellings are soft, flabby, and usually sur- 


DISEASES OF THE SKIN 


221 


rounded by but little redness. If one is allowed to break, it is 
usually followed by a crop of others, wherever the pus from the 
first one has touched. The treatment consists in cleanliness, 
opening of the lesions, and vaccines made from the bacteria 
recovered from the furuncles themselves. Special care should 
also be paid to building up the patient’s general health, thus 
increasing his resistance. 


SCABIES 

Scabies is a parasitic disease frequently seen in dispensary 
practice. It is readily transmissible so that usually all of the 
members of an infected family have the disease. The lesions 
are caused by a minute insect, the Acarus, the females of which 
burrow under the skin, laying their eggs as they go. This 
causes itching and scratching with secondary infection. The 
arrangement of the lesions in lines, following the course of 
the burrows, is characteristic. In adults the disease is most 
common where the skin is thinnest, particularly between the 
fingers; but in infants, whose skin is everywhere tender, the 
lesions may be found anywhere. In nursing infants the disease 
frequently starts on the face, which has become infected from 
the breast of the mother. The treatment consists in a bath 
with hot water and soap, followed by the application of sul¬ 
phur ointment, io per cent. This ointment is applied for sev¬ 
eral successive days, at the end of which time the patient is 
again bathed and fresh clothes put on. All bed linen and under¬ 
wear which may have become infected must be boiled. It is 
useless to treat one member of an infected family without treat¬ 
ing them all, as the patient will presently become reinfected. 
After the treatment with sulphur ointment has destroyed the 
parasites, some mild treatment such as boric acid ointment is 
often necessary to counteract the inflammation and the super¬ 
ficial infections. 


222 TEXTBOOK OF PEDIATRICS FOR NURSES 


PEDICULOSIS 

Of the three forms of pediculosis, only the form which 
attacks the head, the pediculosis capitis, is common among 
children in this country. The head louse lives among the hairs 
of the scalp and lays its eggs upon the hairs. These nits are 
minute pearl-like bodies glued tightly to the hair; they can 
thus be differentiated from flakes of dandruff because, unlike 
the latter, they will not slip along the hair. Aside from the 
presence of pediculi and nits, the symptoms are itching of the 
scalp and swelling of the glands at the border of the scalp. 
In neglected cases infection takes place, with the formation of 
crusts and matting of the hair. The disease is more common 
in girls than boys and is frequently found in institutions, where 
its elimination is often a difficult problem. There are many 
forms of treatment, the simplest of which is to soak the scalp 
with crude petroleum and apply a dressing to keep it in place. 
After twenty-four hours the scalp may be shampooed. Dilute 
acetic acid or vinegar is useful in loosening the cement which 
holds the nits to the hairs. In some institutions all of this 
trouble is obviated by the wholesale use of clippers. Every 
child admitted to a hospital or other institution should have the 
scalp carefully examined and, if found to be infected, should 
be isolated until the scalp can be cleared by treatment. 


CHAPTER XX 

THE NEUROTIC CHILD 




















































































- 


















































CHAPTER XX 


THE NEUROTIC CHILD 

In our present-day complex civilization the nervous child is 
coming to be more and more in evidence. He forms a difficult 
problem for his parents, nurse, and physician. If his condition 
is allowed to go on unchanged he grows up a trial to himself 
and to his associates. Nowhere is so much patience necessary 
or so much gentle firmness demanded as in handling these chil¬ 
dren. Each presents his own particular perversions of thought 
or habit, but the underlying elements of willfulness, selfishness 
and lack of restraint are present in them all. 

Heredity and Environment. —How much of a child’s disposi¬ 
tion is inherited from his parents and how much is later ac¬ 
quired from them by daily association is hard to say. Cer¬ 
tainly nervous instability is a trait which runs through genera¬ 
tions in some families. On the other hand, when one sees how 
a nervous, irritable child becomes quiet and placid when put 
in well-ordered surroundings, one cannot help feeling that the 
neurotic child is what he is because he is brought up by neurotic 
parents. Probably both factors play a part. 

Children react amazingly to the state of mind of those about 
them. If the parents or nurse are worried or harassed or 
fatigued, the child feels it and is irritable and contrary. The 
nagging parent is rewarded by a nagging child. The over- 
indulgent parent is perhaps even worse, for the child becomes 
willful and selfish, and when not given his own way is apt to go 
off into fits of uncontrollable temper. When parents learn that 
they cannot tell falsehoods to children without losing the con¬ 
fidence of the child, they have eliminated a great source of 

225 


226 TEXTBOOK OF PEDIATRICS FOR NURSES . 


difficulty. The statement “Don’t do that or mother will spank,” 
when disobeyed and not followed by the promised spanking is 
like the cry of “Wolf, Wolf,” and soon leads to a total disre¬ 
gard of the parent’s commands. This is especially true of 
those who have unpleasant duties to perform for children as is 
the case with nurses and doctors. “This won’t hurt,” when 
you know it will, betrays the child’s confidence and makes all 
future dealings with him difficult. It is far better to say, “This 
is going to hurt. I want you to be a brave fellow and not 
make a fuss.” Then when you tell him something else is not 
going to hurt, he will believe you. 

Discipline is absolutely essential if one is to avoid having 
a nervous child. By this I do not mean corporal punishment. 
Discipline must begin with the parent himself. It is useless 
for a father to scold his son for not hanging up his coat and 
hat when he comes in, if the father himself flings his things 
on the first convenient chair when he enters the house. And 
no amount of punishment will make the boy really orderly 
under such circumstances. Discipline, then, must come through 
activity properly directed, not through restraint and punish¬ 
ment. 

Need of Play. —Children have the unbounded energy of all 
young creatures and the outlet for this energy is play. Play 
should not be regarded as a waste of time but as a necessity. 
It is the serious business of a child’s life. For proper play 
three things are necessary; other children of about the same age, 
a place to play, and suitable things to play with. An only 
child without playmates seldom develops normally. When a 
mother tells me that her child will not stay outdoors and play, 
I am usually right in assuming that she will not let him play 
with the other children in the neighborhood. Likewise he must 
have a place indoors and one outdoors which he can consider 
his own, and where he and his comrades can play their own 
games without interference. And he must have things to play 
with. The mother who complains that her son is a bad, de- 


THE NEUROTIC CHILD 


227 

structive boy and has ruined a valuable set of furniture with 
his new Christmas saw, is quite taken back when asked why 
she has not found him some soft lumber with which to work. 
Playthings need not be expensive or elaborate. A doll house 
built, under supervision, by the girl herself out of soap boxes 
is enjoyed far more and is more instructive than the most per¬ 
fect one her parents can buy. The child needs this outlet of 
play, and lacking it turns his energies to less wholesome chan¬ 
nels. 

Each nervous child presents a different problem with dif¬ 
ferent underlying causes. There have been given only the 
merest suggestions of the factors in the family and in the home 
which are important. There are many other influences which 
play upon the nervous development of the child, his school, 
the bustle and noise of the city streets, the motion pictures. 
This last is mentioned because there has sprung up within 
the last few years a special type of nervous child from 
among those who frequent the moving pictures. All of these 
things may be factors in producing nervous children and, in 
the case of the nervous child, must be inquired into at 
length. 

CHARACTERISTICS OF THE NERVOUS CHILD 

Physically the neurotic child is usually poorly nourished. 
His appetite is fickle and his digestion frequently upset. He 
notices hurts which the average child would disregard. Often 
he will complain that his clothing is uncomfortable, in particu¬ 
lar he dislikes anything about his neck. He sleeps poorly and 
complains of his dreams. Usually he is bright and his mind 
active, but he tires easily. All children lack concentration 
and the faculty of sustained effort, but in the nervous child 
this lack is especially noticeable. He is affectionate and jeal¬ 
ous but subject to sudden changes in his likes and dislikes. 
These children fall easily into bad practices which soon become 


228 TEXTBOOK OF PEDIATRICS FOR NURSES 


fixed habits. A few of these habits which are the most com¬ 
mon are taken up here. 

Thumb-sucking. —A certain amount of sucking seems natural 
to all children, and becomes objectionable only when persisted 
in after the first year, or carried out in some unusual manner. 
If not corrected many children will continue sucking well into 
their school days. If the effort is then made to correct them 
they become deceitful and sullen, stealing off at every oppor¬ 
tunity to suck the thumb in solitude. As an example of a per¬ 
nicious form of sucking, some children suck the first two fin¬ 
gers, inserting them with the palm forward. This brings 
strong pressure upward on the hard palate and teeth so that it 
soon changes the shape of the mouth. In consequence it is 
always better to prevent the formation of the sucking habit 
or overcome it before it becomes firmly fixed. 

In my experience the most humane method is to cover the 
hands with bags made of unbleached muslin, which can 
be drawn on like mittens and pinned to the sleeves. Most 
children will not put this material in the mouth, while they 
will all others, and in a few days or weeks have forgotten the 
thumb. In some cases cardboard splints on the elbows are 
satisfactory. Bitter substances painted on the fingers are use¬ 
less, the child usually sucking off the quinin or aloes with much 
relish. 

Nail-biting. —A similar habit in older children is that of bit¬ 
ing the nails. This is particularly common in children who 
are for any reason much shut in the house. It is an annoying 
practice to watch, and spoils the shape of the fingers. It is a 
difficult habit to overcome. The general condition of the child 
must be improved as far as possible and active outdoor play 
encouraged. Punishments are useless as they are in all of 
these conditions; rewards, however, often produce results. A 
manicure set will sometimes bring about a speedy cure in a 
girl as it encourages her to keep the nails looking well. 

Masturbation. —It is very much a question whether frequent 


THE NEUROTIC CHILD 


229 


masturbation produces mental deterioration, or whether the 
mentally deficient child is the one who becomes the confirmed 
masturbator. At any rate the two conditions often exist to¬ 
gether. Even babies and very young children of both sexes 
may be victims of the habit which they practice in various 
ways. Every effort should be made to prevent the develop¬ 
ment of this habit by checking it at the start. Once it becomes 
fixed, an entire change of surroundings, associates, and activi¬ 
ties is sometimes necessary to break it. 

Breath-holding. —A peculiarly distressing habit which occurs 
in the spoiled child is holding the breath. The child, if not al¬ 
lowed to have his own way, starts to cry. After a moment or 
so he draws in his breath in a series of convulsive gasps, and 
holds it until in a few seconds the lips become blue and then 
the whole face becomes dusky. After what seems like many 
minutes, though in reality it is usually only thirty seconds, 
there is a prolonged cry and the normal color returns. Some¬ 
times at the height of the cyanosis the child faints, whereupon 
breathing is recommenced, and in a few seconds consciousness 
is regained. The treatment of the attack is to splash cold water 
in the face, if that is at hand; lacking that, the child may be 
given a sharp slap on the buttocks. Cure of the underlying 
condition lies in reeducating the child to the point where he 
realizes he cannot always have his own way. 

Rumination. —A dangerous and often fatal habit in infants 
is rumination. It consists in bringing a mouthful of food 
up from the stomach, chewing it for a time, and then swallow¬ 
ing it again or spitting it out. The food is brought up by a 
peculiar backward and forward working of the lower jaw. 
As the habit progresses, more and more food is brought up at 
a time, until after a few weeks a bottle is hardly taken before 
it is vomited. These children are often very sly in their ways, 
apparently realizing that they are doing something wrong. 
As long as they are watched they refrain from working their 
jaw, but once they think they are unobserved the process com- 


230 TEXTBOOK OF PEDIATRICS FOR NURSES 



Fig. 24.—Ruminator Cap. This cap is made of heavy muslin. The 
lower bands cross on. the point of the chin. They are drawn tight, and 
tied securely to the upper tapes. 


mences and vomiting takes place. No change in diet has any 
permanent effect on the vomiting, as it does not depend on 
indigestion. If allowed to continue, the habit frequently 




THE NEUROTIC CHILD 


231 


proves fatal, as the child does not retain enough food to sus¬ 
tain life. Treatment consists in applying a tight binder to 
the head in such a way that the chin cannot be moved. This 
is adjusted as soon as a bottle has been taken and is kept in 
place for three hours, during which time the food has had 
time to leave the stomach. The cap is then removed and the 
child given an hour’s rest before the next feeding. 



Fig. 25.—Ruminator Cap Applied. 


Enuresis.— Most children by the time they are a year and a 
half old have learned to keep dry during the day. By the 
time they are two and a half they will usually stay dry at night, 
if picked up at ten or eleven o’clock. When a child has not 
learned to keep dry at a reasonable age, he is said to have 
enuresis. This is divided into two types, diurnal and noc¬ 
turnal. Sometimes enuresis depends upon some physical irri¬ 
tation, such as a tight or inflamed foreskin, a vaginitis or the 
presence of pin-worms. Occasionally it depends on habits of 
eating or drinking—salty food for supper with a consequent 
drinking of large amounts of water before retiring, naturally 
predisposing to bed-wetting. It may at times depend on a 




232 TEXTBOOK OF PEDIATRICS FOR NURSES 

generally run-down condition in children of nervous tempera¬ 
ment. But the great majority of cases are the result of habit. 
The parents have either neglected to train the child properly, 
or they have not known how to go about the training. 

In both types of enuresis the general health of the patient 
should be brought up to the highest possible point and any 
local conditions corrected. The urine should be examined and, 
if this be a cause of irritation, steps should be taken to correct 
the fault. With these matters attended to, the actual treat¬ 
ment commences. This is tedious and requires much time. 
One notices first how often the child wets himself. Let us 
say that it is every twenty minutes. Every twenty minutes, 
then, throughout the day he is placed upon the chamber and 
encouraged to void. After he has stayed dry for three days, 
the time is increased to twenty-five minutes, and so on until 
he is staying dry for an hour and a half or two hours. By 
this time he has usually learned enough control so that if for 
any reason he needs to urinate before the allotted time is up, 
he can overcome the impulse until he can reach the chamber. 
This routine gradually increases the capacity of the bladder 
and teaches control of the sphincter. When this control is 
acquired during the day one can begin the treatment of noc¬ 
turnal enuresis with some hope of success, but not before. 
In starting the night training one should first make it as easy 
for the child as possible by regulating the intake of fluids. A 
satisfactory plan is to give all the fluids the child wants up to 
four-thirty in the afternoon, after which time none are allowed, 
not even with the supper, which is dry and free from salty or 
highly seasoned food. Just before being put to bed, the child 
is made to void. He is wakened and made to void again about 
ten. If experience shows that he is wet at that time, one must 
get him up sooner. Most children will then go through to 
four or five in the morning at which time they must again 
be picked up. After a few weeks the early morning voiding 
can usually be postponed till rising time. Relapses frequently 


THE NEUROTIC CHILD 


233 


occur, particularly if the child has a cold or other minor ail¬ 
ment, whereupon one must patiently begin over again with the 
education. 

Speech Defects. — Lisping .—Lisping and the use of baby 
talk occasionally depend on difficulty in breathing or on abnor¬ 
malities of the throat, tongue or teeth. More often, however, 
they depend on faulty training. 

Many parents encourage these habits in their children by 
copying them, instead of trying to train them to speak dis¬ 
tinctly. The treatment consists primarily in always speaking 
clearly and slowly to the child. Further, he should have a 
few minutes training each day upon the sounds which for him 
are difficult, usually s, th, and r. It is far better to give him 
an intensive lesson of ten or fifteen minutes and leave him in 
peace the rest of the day than to be constantly correcting him. 

Stammering .—Many nervous children between the ages of 
three and six have short periods of stammering which, while 
not serious, fill the parents with apprehension. The condition 
can usually be overcome by insisting that the child speak slowly. 
He stammers only because his thoughts get ahead of his tongue. 
The real stammerers, on the other hand, have no such hope of 
easy cure. Special schools help many of them, although the 
majority slip back into their old ways when out of the routine 
of the school. 

Tics. —Tics are purposeless movements which have been 
carried out so frequently that they have become fixed habits. 
We all have our pet tic which goes with us through life. It 
may be a clearing of the throat when embarrassed, a stroking 
of the ear when in deep thought, or an almost irresistible im¬ 
pulse to step on every crack in a given stretch of sidewalk. 
But the nervous child, instead of one or two, has a dozen tics 
and is constantly changing his assortment. For a few weeks 
he may be constantly drawing down his upper lip over the 
lower, then perhaps he will start hitching up one shoulder, and 
so on, until his parents and teachers are in despair. Treat- 


234 TEXTBOOK OF PEDIATRICS FOR NURSES 

ment is difficult because correcting the habit fixes the child’s 
attention upon it and tends to make it more lasting. Punish¬ 
ments are of no avail, nor are rewards for the same reason. 
Treatment then must be along general lines, building up the 
general health by means of outdoor exercise and plenty-of 
sleep. The child’s time must be taken up with interesting occu¬ 
pations. And finally he should not associate with those who 
are afflicted like himself, because such association leads to 
the acquiring of new tics by imitation. 

Pica. —The habit of eating unusual things such as dirt and 
chalk is called pica. Often such a perverted appetite is an 
indication of a faulty diet, but sometimes no such basis can 
be found. The seriousness of the habit depends upon the sub¬ 
stance which the child elects to eat. Grass or shavings or 
soap may do little or no harm. Hair and thread, on the other 
hand, have a tendency to form in time a large ball in the stomach 
which finally impairs digestion and necessitates an operation. 
One of the most common and perhaps the most dangerous types 
of pica is paint eating, common because the child lives in a paint 
encrusted environment, and dangerous because of the lead of 
which the paint is made. Lead poisoning manifests itself in 
anemia, vomiting, a bluish line of deposited lead in the gums, 
and, in advanced cases, convulsions and death. Infants who 
eat paint should be in cribs of natural wood or of metal 
painted with zinc paint. Older children usually chew the 
paint from the sill while looking out of the window. They 
require constant watching to correct the habit. 


CHAPTER XXI 


THE CONVALESCENT CHILD 







































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. 























CHAPTER XXI 


THE CONVALESCENT CHILD 

The child who is recovering from a long or debilitating 
illness presents many problems for the nurse to solve. Strictly 
speaking, this group would be a relatively small one, but there 
are other children whose care is so closely related to the con¬ 
valescent that they may be included in this chapter. These 
are the children with the milder forms of heart or kidney 
disease who do not feel sick, and who still have not the strength 
to romp and play as do normal children. Also in this category 
come patients who are much under weight, whether from 
faulty care, from latent tuberculosis or some other such cause. 
These children are all bankrupt physically, and the task is to 
bring them up so that they not only have enough strength for 
the day’s needs but have a reserve which may be drawn on in 
an emergency. 

Mental State. —Most of these patients are very unstable 
nervously. They are fussy and exacting. If one caters to 
their wants they become little tyrants, making every one about 
them miserable slaves. If they cannot have their own way 
they frequently fly into a rage and scream till exhausted. And 
so one must steer a middle course between overindulgence 
which results in a spoiled child and too great strictness with its 
resulting tantrums and fatigue. 

Physical State. —The characteristic feature of these children 
is the ease with which they tire. If in bed, they constantly 
interrupt their play by dropping back on the pillows for a few 
moments rest. When they are allowed up, one must remem¬ 
ber this, and make the first excursions from bed brief, only 
increasing the time as the child’s strength returns. 

237 


238 TEXTBOOK OF PEDIATRICS FOR NURSES 

Rest. —The one most important factor in the care of the con¬ 
valescent is rest. In order that this shall be as complete as 
possible it must be made comfortable. For the child in bed, 
care must be taken to remove toys and heavy books from 
the covers when he settles himself for a rest or nap. Where 
possible he should be moved occasionally to another bed, so 
that his may be aired and remade. After each meal, all crumbs 
should be carefully brushed from the bedding. If he wears 
a robe while sitting up to play, this should be removed when 
he lies down. Once or twice each day at definite times there 
should be regular naps. For these the room should be par¬ 
tially darkened and the windows opened as much as the weather 
will allow. 

For the child who has improved to the runabout stage, there 
should be a long rest after the midday meal. With some chil¬ 
dren one need only remove the shoes and loosen the outer 
clothing and cover them with blankets. Others will not rest 
in this way, and must be put into their night clothes and regu¬ 
larly put to bed. An hour should be the minimum after¬ 
luncheon rest for any of these children. It should be remem¬ 
bered that the child will rest much more completely if alone. 
Persons moving about or even sitting quietly in the room dis¬ 
tract him and keep him from relaxing. 

Bathing and Massage.— We know far too little of the effects 
of baths upon the system. But certainly a warm bath is sooth¬ 
ing and is helpful in inducing a peaceful night’s sleep. And 
in some children a cold shower in the morning is invigorating. 
This latter should be used with care, however, and should 
never be tried without the definite order of the physician. 
Gentle massage once or twice a day is of considerable value 
with children who have long been confined to bed. 

Food.— It was said of the normal child that he must never 
be urged to eat. This does not apply with the same force 
to the convalescent child. While actual forcing of food leads 
only to gagging and vomiting, one can often increase the 


THE CONVALESCENT CHILD 


239 


child’s interest in his food in ways which help rather than 
hinder his digestion. His toast may be cut with cookie cutters 
into various amusing shapes. Milk often tastes far better 
through a straw. A few vermicelli letters will often dispose 
of a cup of broth which might otherwise go untouched, and 
so on. Children often eat better with others than alone, so 
that a “tea party,” with mother and nurse as guests, is often 
an excellent appetizer. A variation is a doll’s party with food 
served on the doll’s tea set. For a hundred tempting dishes 
see any book on dietetics. But remember that two small por¬ 
tions are as much as one large one, and are twice as well taken. 
It is usually a mistake to give frequent feedings even to the 
child who is taking but little at a time. Four meals a day at 
stated intervals are all that are necessary. 

These children, with the exception of certain of the heart 
and kidney cases, are usually benefited by increasing their fluid 
intake above the normal. To this end, water and fruit-juice 
drinks are desirable. Orangeade and limeade may be made 
with charged water for variety’s sake. Grapejuice with a little 
lemon and cracked ice sometimes goes well. Older children 
often enjoy an occasional small glass of ginger ale. 

Entertainment.— As the child’s strength returns he will 
spend less and less of his time simply resting and one must 
find amusements for him. He cannot play actively all of the 
time he is not resting, and to avoid boredom he must be enter¬ 
tained. All children love stories, whether told or read to 
them, provided the stories fit the age and the temperament of 
the child. They demand repetition and would rather hear the 
same favorite story over and over than to be always told new 
ones. Simple tales of everyday happenings please a child 
more and are less apt to make him have bad dreams than fan¬ 
tastic fairy tales. For this reason Robert Louis Stevenson’s 
A Child's Garden of Verses is especially loved by children. 
There are many good lists of books for children of various 
ages. One which has proved very satisfactory is A Mother's 


240 TEXTBOOK OF PEDIATRICS FOR NURSES 

List of Books for Children by Gertrude Weld Arnold. When 
it comes to the manner of telling, Sara Cone Bryant's How to 
Tell Stories to Children is most helpful. When one’s voice 
gives out, the phonograph may be called upon. There are 
barnyard records, bird songs, and fables to please children of 
all ages. For children who like animals, the right kind of a 
dog will while away many otherwise weary hours. 

Play. —When the child is well enough to sit up and play, 
he should be comfortably gowned and propped up with pillows 
or a back rest. A bed table is almost indispensable. A fairly 
satisfactory one may be improvised from a lapboard and two 
empty shoe boxes. One should be careful not to litter the bed 
with numerous toys. One thing at a time is enough, and 
when this is tired of it should be taken away and another 
substituted. Blocks are unsatisfactory, as a bed table at best 
is unstable and a change in position may cause an earthquake 
which destroys a carefully erected building, much to the child’s 
sorrow. Toy villages of light wood are, for this reason, much 
to be preferred. For a like reason, painting, with its inevit¬ 
able cup of water, is dangerous, and should be replaced by 
work with colored pencils. Many of the cut-out toys are 
entertaining, but one should avoid the more complicated ones, 
and especially those in which there is much pasting, as the 
paste seldom holds well and the child is annoyed by his failure 
to reach perfection. There are games almost without number 
for older children to play. The only danger is that the child 
may tire himself out in his excitement. So one must watch 
carefully and stop him before he becomes fatigued. 

The child who is well enough to be up and about the room 
enjoys building-blocks. He may also sit at a table and model 
with clay or one of its substitutes. Painting and blowing soap 
bubbles are both applicable at this stage. For numerous other 
suggestions one may see Dorothy Canfield’s What Shall We 
Do Nowf 

Education.— In some conditions convalescence is so pro- 


THE CONVALESCENT CHILD 


241 


tracted that the child’s schooling is definitely interfered with, 
and some means must be taken to make up this deficiency. This 
is particularly true of orthopedic cases. For such children 
a hospital school where they can be both treated and taught is 
highly desirable. For children at home the Calvert School 
has an admirable system for guiding the mother or nurse in 
teaching the child. 

Fresh Air and Sunshine. —Fresh air and sunshine are such 
wonderful tonics that one should make use of them wherever 
possible with convalescent children. In good weather the bed 
may be rolled out on to an open balcony or porch. Later the 
child may have his play table on the porch or lawn. When 
out-of-doors he must be watched for evidences of fatigue even 
more carefully than when in the house and must be made to 
rest if these appear. When the season of the year makes out¬ 
door activities unwise, it is sometimes advisable to move the 
patient to a warmer climate. 














INDEX 


Abdominal Massage, in prolonged 
indigestion, 128 

Abdominal pain, in smallpox, 165 
Abortion, syphilis causing, 209 
Acarus, scabies caused by, 221 
Acidosis, complicating diarrhea, 
124 

Acquired syphilis, 209 
Active immunization, in diphthe¬ 
ria, 155 

Acute poliomyelitis, 177 
Adenitis, cervical, influenza com¬ 
plicated by, 173 

-in occult fever, 141 

-tonsillitis, causing, 186 

“Adenoid facies,” 182 
Adenoids, 181 

— associated with hypertrophied 
tonsils, 185 

— etiology, 181 

— symptoms, 181 

— treatment, 182 
Adrenalin, 97 

— dosage of, 98 

— in secondary pneumonia, 202 
Age, drug dosage according to, 

98 

Ailments, minor, effect on ma¬ 
ternal milk, 49 

-effect on weight, 4 

Airings, importance of, 23 
Albolene, in adenoids, 182 
Aloes, thumb-sucking in spite of 
use of, 228 

Anal condylomata, in hereditary 
syphilis, 210 

Anemia, from protein deficiency, 

4i 

— in influenza, 173 

243 


Anemia, in scurvy, 120 

— tonics for, 97 

Anorexia, see Appetite, loss of 
Anterior poliomyelitis, acute, 177 
Antimeningococcus serum, 99 
Antipyretics, use of, 96 
Antipyrin, dosage of, 98 

— in croup, 190 

— in follicular tonsillitis, 185 

— in influenza, 173 
Antirachitic vitamin, 43, 115 
Antiscorbutic vitamin, 43, 120 

— destroyed by boiling, 61 
Antitoxin, diphtheria, 155 

-preparation and use of, 99 

Artificial feedings, 59, see also 

Feeding, artificial 
Argyrol, in adenoids, 182 

— in follicular tonsillitis, 185 
Arsenic, anemia an indication 

for, 97 

— dosage of, 98 

Arsphenamin, in treatment of 
syphilis, 211 
Aspirin, in mumps, 165 

— in septic sore-throat, 183 

— in weaning, 55 
Atropin, dosage of, 98 
Aural irrigation, 96 
Average growth, 3 

— height, 5 

— weight, 4 


“Baby-talk,” a bad habit, 8 
Bacillus, Bordet-Gengon, 160 

— Klebs-Loffler, 153 

— Pfeiffer, 171 

— tubercle, 205 



244 


INDEX 


Bands, 27 
Barley water, 67 
Bassinet, 13 
Bath, drying after, 22 

— eliminated in care of prema¬ 
ture baby, 38 

— extra, 22 
—'first, 18 

— in convalescence, 238 

— in smallpox, 168 

— paraphernalia desirable, 18 

— preliminaries, 20 

— proper, 21 

— soap for, 20 

— sponge, 21 

-in scarlet fever, 142 

— temperature of, 19, 21 

— towels for, 19 

— water for, 19 

Baths, cold sponge, temperature 
reduced by, 97 
Bed, for infant, 13 
Bed-wetting, 231 
Beef broth, 70 
Belladonna, dosage of, 98 
Benzoin, compound tincture of, 
195 

Biological preparations, 98 
Birth, diseases incident to, 103 

— weight at, 3 
Bladder, training of, 25 
“Blue ointment,” 211 

Boiling, antiscorbutic vitamin de¬ 
stroyed by, 61 

Bones, rachitic changes in, 116 

— scurvy causing changes in, 
119 

— tuberculosis of, 206 
Books, germs harbored in, 138 
Bordet-Gengou bacillus, 160 
Boric acid solution, aural irriga¬ 
tion with, 96 

—'in care of breasts, 49 
Boston feeder, 34, no 

— feeding, 66 


Bottle, method of giving, 66 

— size of, 64 
Breasts, care of, 49 

— during weaning, 55 
Breast-feeding, artificial and, 56 

— excessive milk supply, 51 

— in prematurity, 33 

— insufficient milk supply, 50 

— measles immunity acquired, 43 

— rapid growth from, 4 

— rickets prevented by, 117 

— when begun, 18 

— See also Maternal nursing 
Breath-holding, 229 

Bromids, in cerebrospinal menin¬ 
gitis, 175 

— in tetany, 119 
Bronchitis, 193 

— etiology, 193 

— influenza complicated by, 172 

— inhalations in, 95 

— in smallpox, 166 

— mustard plaster in, 90 

— pneumonia following, 200 

— prognosis, 194 

— rickets causing tendency to¬ 
ward, 116 

— symptoms, 193 

— treatment, 194 
Bronchopneumonia, measles com¬ 
plicated by, 144 

Broth, beef, in prolonged indi¬ 
gestion, 128 

Brown mixture, for cough in 
measles, 146 
Buttermilk, 69 

— in diarrhea, 125 

— in prolonged indigestion, 128 

Caffein, 97 

— dosage of, 98 

— in secondary pneumonia, 202 
Calcium, deficient in rickets, 116 

— tetany due to deficiency of, 118 



INDEX 


Calomel, 97 

Calories, number required, 43 
Calvert School system of teach¬ 
ing, 241 

Camphor, in adenoids, 182 
Cap, ruminator, 230 
Caput succedaneum, 105 
Carbohydrates, diarrhea caused 
by excess of, 42 

— per cent in milk, 59 
Carbolated glycerin, in treatment 

of otitis media, 187 
Carbolated vaselin, for itching in 
smallpox, 168 
Carriers, diphtheria, 154 
Cascara, 97 

— dosage of, 98 

— for constipation in nursing 
mother, 48 

— in influenza, 173 

Catarrhal spasm of larynx, 
189 

Cathartics, saline, not advisable 
for nursing mothers, 48 
Catheterization, 83 
Cereals, following intubation, 159 

— volume of, 65 
Cerebrospinal meningitis, 174 

— etiology, 174 

— quarantine, 175 

— symptoms, 174 

— treatment, 174 
Characteristics, of nervous child, 

227 

Chest, influence of health upon, 6 
Cheyne-Stokes breathing, in tu¬ 
berculous meningitis, 176 
Chickenpox, 147 

— complications, 148 

— etiology, 147 

— incubation period, 148 

— symptoms, 148 
■—treatment, 149 

Children, older, diets for, 73-76 
Chloral, dosage of, 98 


245 

Chloral, in cerebrospinal meningi¬ 
tis, 175 

—rectal administration of, 90 
Chloroform, in cerobrospinal 
meningitis, 175 

Chvostek’s sign, in tetany, 118 
Citrate of magnesia, 97 
Cleft palate, 109 
Clothing, details of, 26 

-band, 27 

-diaper, 27 

-dress, 29 

-night clothes, 29 

-petticoat, 29 

-shirt, 29 

-socks or booties, 29 

-summer, 29 

Codein, 97 

— dosage of, 98 

— in bronchitis, 195 

— in measles, 146 

— in secondary pneumonia, 202 

— in weaning, 55 

Cod-liver oil, antirachitic vita¬ 
min in, 43, 115 

— dosage of, 98, 117 

— for premature baby, 38 

— in bronchitis, 195 

— in diarrhea, 126 

— in scurvy, 120 
Colic, 51 
Colostrum, 3, 52 
Complementary feeding, 56 
Complications, in follicular ton¬ 
sillitis, 185 

— in otitis media, 187 

— in primary pneumonia, 198 

— in secondary pneumonia, 202 

— of septic sore-throat, 183 

— in smallpox, 166 
Compound tincture of benzoin, 

195 

Condensed milk, 69 
Condylomata, anal, in hereditary 
syphilis, 210 



INDEX 


246 

Constipation, in nursing mother, 
48 

— oatmeal water for, 68 

— pyloric stenosis accompanied 
by, 130 

Contagious diseases, table of, 166, 
167 

—• — chickenpox, 166 

-diphtheria, 166 

-German measles, 166 

-measles, 166 

-mumps, 167 

-scarlet fever, 167 

-smallpox, 167 

-whooping-cough, 167 

Contagious impetigo, 220 
Convalescent child, 237 

— bathing, 238 
—• education, 240 

— entertainment, 239 

— food, 238 

— fresh air, 241 

— massage, 238 

— mental state, 237 

— physical state, 237 

— play, 240 

— rest, 238 

— sunshine, 241 

Convulsions, chloral by rectum 
for, 90 

— in cerebrospinal meningitis, 
174 

— in diphtheria, 154 

— in smallpox, 165 

— in tetany, 118 

— in tuberculous meningitis, 176 

— in whooping-cough, 162 

— mustard pack as emergency 
measure in, 89 

Cool sponge, 21 

Cord, umbilical, hemorrhages 
from, 106 

-management of, 17 

Cornstarch, as a dusting powder, 
22 


Coryza, as a symptom of heredi¬ 
tary syphilis, 209 
Cracked nipples, treatment of, 49 
Crede’s treatment of eyes at 
birth, 17, 107 
Creeping, 7 

Cretinism, fontanel closure de¬ 
layed in, 6 

— thyroid extract in, 100 
Crib, when used, 13 

Crisis, in primary pneumonia, 198 
Crude petroleum, in treatment of 
pediculosis, 222 
Croup, 189 

— etiology, 189 

— inhalations in, 95 

— membranous, 153 

— not to be confused with mem¬ 
branous croup, 153, 189 

— prognosis, 190 

— symptoms, 189 

— treatment, 189 

Croup kettle, care in use of, 95 
Croup tent, construction of, 95 
Curds, 60, 68 

— in diarrhea, 125 

Cyanosis, breath-holding produc¬ 
ing, 229 

— in secondary pneumonia, oxy¬ 
gen for, 202 

Cyclic vomiting, 128 

— etiology, 128 

— prognosis, 129 

— symptoms, 128 

— treatment, 129 

Dandruff, treatment of, 21 
Defects, of speech, 233 
Dentition, difficult, 10 

— irregular, 11 

— “six-year molars,” 11 
Desquamation, in scarlet fever, 

1 41 

Diabetes, insulin in, 100 



INDEX 


247 


Diabetes, weaning indicated in, 54 
Diagnostic methods, 79 
Diagnostic methods, collection of 
urine, 82 

— holding child, 81 

— pulse, 80 

— respiration, 80 

1 —temperature, 79 

— weight, 81 

— wrapping child, 82 

Diaper, dysentery necessitating 
special care of, 138 

— laundering of, 28 

— rubber cover for, 28 

— square, 28 

— triangular, with pad, 27 
Diarrhea, 123 

— carbohydrate causing, 42 

— complications, 124 
-acidosis, 124 

— etiology, 123 

— in whooping-cough, 162 

— prognosis, 125 

— symptoms, 123 

— treatment, 125 

Diet, for older children, 73-76 

— in scarlet fever, 141 

— of nursing mother, 47 

— vomiting caused if too rich, 
132 

Difficult dentition, 10 
Digestion, disorders of, 123 

-cyclic vomiting, 128 

-diarrhea, 123 

-intussusception, 131 

—• — prolonged indigestion, 126 

-pyloric stenosis, 129 

-vomiting, 131-133 

Digitalis, dosage of, 98 

— indication for, 97 

— in secondary pneumonia, 202 
Diphtheria, 153 

— active immunization, 155 

— antitoxin, 155 

-preparation and use of, 99 


Diphtheria, carriers, 154 

— complications, 154 

— etiology, 153 

— laryngeal, 156, see also Laryn¬ 
geal Dipththeria 

— pneumonia following, 200 

— prognosis, 154 

— prophylaxis, 154 

— quarantine, 160 
—* Schick test, 154 

— symptoms, 153 

— tonsils as foci of infection in, 
182 

— toxin-antitoxin, 99, 155 

— treatment, 155 

Disease, contagious, table of, 166, 
167 

— fontanel closure affected by, 6 

— incident to birth, 103 

— intestinal, weight disturbing, 5 

— respiratory, see Respiratory 
diseases 

— skin, 215 

-eczema, 216 

-furunculosis, 220 

-impetigo contagiosa, 220 

-intertrigo, 218 

-milaria, 219 

-pediculosis, 222 

-scabies, 221 

-seborrhea, 219 

Diurnal enuresis, 231 
Dobell’s solution, in follicular ton¬ 
sillitis, 185 

— in measles, 146 

— in scarlet fever, 142 
Dress, 29 

Dried junket, 68 
Dried milk powders, 69 
Drip, Murphy, in cyclic vomiting, 
129 

— nasal, 92 

-in diarrhea, 126 

— rectal, 93 

Drugs, antipyretic, 96 



INDEX 


248 

Drugs, cascara, 97 

— digitalis, 97 

— dosage of, 97, 98 

— gentian, compound tincture of, 

97 

— in tuberculosis, 208 

— laxatives, 97 

— little used in pediatrics, 89, 

96 

— magnesia, 97 

— milk supply not increased by, 

47 

— nux vomica, 97 

— often necessary in smallpox, 
167 

— opiates, 97 

— rhubarb, syrup of, 97 

— sedative, 97 

— stimulants, 97 

— strychnin, 97 

— tonics, 97 
Drying, after bath, 22 
Dysentery, care of diaper in, 138 

Ear, middle, inflammation of, see 
Otitis media 

— outer, cleansing of, 20 

-irrigation of, 96 

Eclampsia, weaning indicated in, 

54 

Eczema, 216 

— complications, 216 
•—etiology, 216 

— intertrigo, 218 

— prognosis, 216 

— symptoms, 216 

— treatment, 216 

Edema, of scalp, caput succe- 
daneum, 105 

Education, during convalescence, 
241 

Electric bottle heater, 66 
Electric pads, precautions in use 
of, 37 


Emotions, maternal, effect on 
child, 48 

Empyema, primary pneumonia 
complicated by, 198 
Enemas, in diarrhea, 125 

— in prolonged indigestion, 128 

— varieties, 90 

Entertainment, in convalescence, 
239 

Enuresis, 231 

— treatment, 232 
Environment, influence of, 225 
Epidemic meningitis, 174 
Epidemic parotitis, 164 

Erb’s sign, 118 

Eruptions, routine observation 
for, 85 

Excreta, disposal of, 138 
Exercise, encouragement desir¬ 
able, 24 
Extra baths, 22 
Ex-tubation, 159 
Eyes, cleansing before bath, 20 

— infection of, ophthalmia neo¬ 
natorum, 106 

— paralysis of muscles in diph¬ 
theria, 154 

— stabismus and nystagmus in 
tuberculous meningitis, 176 

— treatment by Crede’s method 
at birth, 17 


Farina, in mixed feedings, 56 

— preparation of, 69 
Fat, per cent in milk, 59 

—soap curds caused by, 42 

— vomiting caused by, 42 
Feeder, Boston, 34, no 
Feeding, artificial, 59 

-choice of cow’s milk, 60 

—•—frozen milk, 60 

-relative composition of 

milks, 59 

-sterilization of milk, 60 



INDEX 


Feeding-, bottle, 66 

— complementary, 56 

— infant, elements of, 41 

-importance of, 41 

-’intervals, 44 

-methods of, 44 

-technic of, 49 

-time required, 50 

-wet-nursing, 51 

-see also Maternal nursing 

— mixed breast and artificial, 56 

— supplementary, 56 
Feet, covering for, 29 
Fever, drugs for reducing, 96 

— inanition, 111 

— scarlet, 139 

Flannel bands, not desirable, 27 
Flexner’s serum, in cerebrospinal 
meningitis, 174 

-administration of, 174 

Fluids, administration of, 91 

-hypodermoclysis, 91 

-intraperitoneal injection, 92 

-intravenous injection, 92 

-gavage, 95 

-nasal drip, 92 

-rate of flow of, 93 

-— rectal drip, 92 

-transfusion, 93 

— inanition fever necessitating, 
hi 

— in cyclic vomiting, 129 

— intravenously in acidosis, 125 
Follicular tonsillitis, 184 

— complications, 185 

— etiology, 184 

— symptoms, 184 

— treatment, 185 
Fontanel, anterior, 6 

-late closure in rickets, 116 

— bulging in tuberculous menin¬ 
gitis, 176 

— diseases affecting closure of, 6 

— posterior, 6 
Food, elements, 41 


249 

Food, elements, carbohydrates, 42 

-fats, 42 

-proteins, 41 

-salts, 42 

-vitamins, 43 

-water, 42 

— height, affected by, 5 

—- inanition fever from lack of, 
hi 

— in convalescence, 238 

— infant, 67 

-barley water, 67 

— —beef broth, 70 

-buttermilk, 69 

-condensed milk, 69 

-dried junket, 68 

-dried milk powders, 69 

—•— farina, 69 

-oatmeal water, 67 

-proprietary, 69 

-protein milk, 68 

-reenforced protein milk, 68 

-rice water, 67 

-vegetable broth, 70 

— methods of administering, 44 

— mother’s, 47 

— requirements, 43 

— solid, in mixed feedings, 56 

— temperature desired for ga¬ 
vage, 95 

— weight, influenced by, 4 
Foreskin, care of, 20 
Formulas, choice of, 61 

— equipment necessary for prep¬ 
aration of, 61 

— pasteurizing of, 66 

— preparation of, 64 

— table of, 62, 63 

— varieties of, 59 
Fowler’s solution, 97 

— dosage of, 98 

Fresh air, during convalescence, 
241 

Fumigation, following contagious 
diseases, 139 



INDEX 


250 

Furunculosis, 220 

— diarrhea complicated by, 124 

— in smallpox, 166 


Gangrene, intussusception caus¬ 
ing, 131 
Gavage, 95 

— following intubation, 159 

— in diarrhea, 126 

— in pyloric stenosis, 130 

— lavage preceding, 94, 95 
Genitalia, toilet of, 20 
Gentian, compound tincture of, 97 
Gentian-violet, in treatment of 

otitis media, 188 
German measles, 146 
Ginger ale, in convalescence, 239 
Glands, lymphatic, tuberculosis 
of, 206 

Glucose solution in acidosis, 125 

-in cyclic vomiting, 129 

Glycerin, carbolated, in treatment 
of otitis media, 187 
Gonococcus infection, of eye, 
ophthalmia neonatorum, 106 
Grapejuice, in convalescence, 239 
Grip, see influenza 
Growth, of infant, 3 

-during first year, 4 

-of head, 5 

Gums, bleeding in scurvy, 119 

Habit, bed-wetting, 232 

— of sleep, 12 

— toilet, 25 
Harelip, 109 

Head, effect of posture upon 
shape of, 6 

— growth, 5 

— louse, 85, 222 

— measurements, 5 
Headache, in smallpox, 165 
Hearing, 9 


Height, average, 5 
—effect of food upon, 5 

— variations in, 5 
Hemorrhage, due to labor, 105 

— paralysis caused by, no 

— spontaneous, 106 

— transfusion valuable in, 93 
Hereditary syphilis, 209 

— etiology, 209 

— prognosis, 210 

— prophylaxis, 210 

— symptoms, 209 
—'treatment, 211 

— Wassermann reaction, 210 
Heredity, influence of, 225 
Hernia, inguinal, 109 

— umbilical, 108 

-in whooping cough, 162 

Herpes labialis, in cerebrospinal 
meningitis, 174 
Holding, for examination, 81 
Home education, Calvert School 
system for, 241 
Hours of sleep, 12 
Hydrocephalus, fontanel closure 
delayed in, 6 
Hypertrophied tonsils, 185 

— adenoids associated with, 185 

— etiology, 185 

— symptoms, 185 

— treatment, 186 
Hypodermoclysis, 91 

Immunity, acquired from nursing 
mother, 43 

— antitoxins producing, 99 
Immunization, active, in diph¬ 
theria, 155 

Impetigo contagiosa, 220 
Inanition fever, hi 
I ncubation period, German mea¬ 
sles, 147 

— infantile paralysis, 177 

— influenza, 171 



INDEX 


Incubation period, measles, 143 

— scarlet fever, 140 

— smallpox, 165 

— whooping-cough, 161 
Incubator, 34 

Indigestion, acute, vomiting in, 
132 

—chronic intestinal, protein milk 
in, 68 

— lavage of stomach in, 94 

— prolonged, 126 

Infant feeding, see Feeding, in¬ 
fant 

Infant foods, 67, see also Food, 
infant 

Infantile paralysis, 177 

— etiology, 177 

—‘incubation period, 177 

— prognosis, 178 

— quarantine, 178 

— symptoms, 177 

— treatment, 178 

Infection, gonococcus of eye, 
ophthalmia neonatorum, 106 

— newborn very susceptible to, 
107 

— prevention of, 37 

— rickets increasing susceptibility 
to, 116 

Infectious diseases, 137 

— chickenpox, 147 

— diphtheria, 153 
-laryngeal, 156 

— highly, see Contagious diseases, 
table of, 166, 167 

— infantile paralysis, 177 

— influenza, 171 

— isolation in, I37 

— measles, 142 

— meningitis, 173 

-cerebrospinal, 174 

-pneumococcic, 176 

-tuberculous, 175 

— mumps, 164 

— rubella, 146 


251 

Infectious diseases, scarlet fever, 
139 

— whooping-cough, 160 
Influenza, 171 

— bacillus, meningitis caused by, 
176 

— cervical adenitis in, 173 

— complications, 172 

— etiology, 171 

— incubation period, 171 

— isolation, 173 

— otitis media complicating, 173, 
186 

— pneumonia following, 200 

— quarantine in, 173 

— symptoms, 171 
—‘treatment, 173 

— types of, febrile, 172 

— gastro-intestinal, 172 

— nervous, 172 
—respiratory, 171 
Inguinal hernia, 109 
Inhalation, steam, 104 

-in croup, 189 

-technic of, 95 

Injection, intraperitoneal, 92 
-in diarrhea, 126 

— intravenous, 92 
-in diarrhea, 126 

— rectal, 92 

— tuberculin, 208 

— umbilical vein, 106 
Insufficient milk, indications of, 50 
Insulin, in diabetes, 100 
Intertrigo, 218 

Intestinal disease, weight affected 
by, 5 

Intracutaneous test, for tubercu¬ 
losis, 205 
Intubation, 157 
Intussusception, 131 
Ipecac, dosage of, 98 

— syrup of, in croup, 190 
Iron, anemia an indication for, 97 

— bitter wine of, dosage of, 98 



INDEX 


2.52 

Iron, in diarrhea, 126 
—reduced, dosage of, 98 

-in scurvy, 120 

Irregular dentition, 11 
Irrigation, aural, 96 

— rectal, 90 
Isolation, 137 

— books and toys, 138 

— chickenpox, 149 

— doctor, 138 

— food and dishes, 138 

— infantile paralysis, 178 

— influenza, 173 

— linens, 138 

— nurse, 138 

— otitis media, 188 

— ophthalmia neonatorum, 107 

— parasites, 85 

— patient’s room, 137 

— prior to vaginal examination, 
83 

— release from, 139 

— sputum and excreta, 138 
Itching, chickenpox, 149 
Itching, measles, bicarbonate of 

— soda for, 146 

— smallpox, 166 


Jacket, for premature baby, 35 
Joints, tuberculosis of, 206 
Junket, dried, 68 
— following intubation, 159 


Kettle, croup, care needed in use 

of, 95 

Klebs-Loffier bacillus, 153 
Knitted bands of silk and wool, 
27 

Koplik’s spots, 144 


Labor, hemorrhage due to, 105 
Lactic acid milk, in diarrhea, 125 


Laryngeal diphtheria, 156 

— extubation, 159 

— intubation in, 157 

— quarantine, 160 

— tracheotomy in, 160 
Laryngitis, smallpox, 166 
Larynx, catarrhal spasm of, 189 
—spasm in tetany, 118 

Latent tuberculosis, 207 
Lavage, gastric, technic of, 93 
Laxatives, 97 
Lead poisoning, 234 
Limeade, in convalescence, 239 
Linens, sterilization of, 138 
Lisping, 233 
Louse, head, 85, 222 
Lymphatic glands, tuberculosis of, 
206 

Lysis, in primary pneumonia, 198 


Magnesia, citrate of, 97 
-dosage of, 98 

— milk of, 97 

-dosage of, 98 

-in influenza, 173 

— — to remove stains from teeth, 

23 

Marasmus, in cerebrospinal men¬ 
ingitis, 174 

Massage, abdominal, in prolonged 
indigestion, 128 

— in convalescence, 238 
Mastoiditis, otitis media compli¬ 
cated by, 187 

Masturbation, mental deteriora¬ 
tion produced by, 229 
Mattress, disinfection of, 139 
Maternal nursing, 47, 49 
Measles, 142 

— complications, 144 

— etiology, 142 

— German, 146 

— immunity acquired from nurs¬ 

ing, 43 



INDEX 


253 


Measles, incubation period, 143 

— Koplik’s spots, 144 

— otitis media complicating, 186 

— pneumonia following, 200 

— quarantine, 146 

— symptoms, 143 

— treatment, 145 

— tuberculosis complicated by, 

207 

Measurements, of head, 5 
Membranous croup, 153, see also 
Diphtheria 

Meningitis, cerebrospinal, 174 
-See also Cerebrospinal men¬ 
ingitis 

— etiology and types of, 173, 176 

— influenza bacillus causing, 176 

— pneumococcic, see Pneumococ- 
cic meningitis 

— tuberculous, see Tuberculous 
meningitis 

Menstruation, return of, 49 
Mental state, in convalescence, 
237 

— of mother, effect on child, 
48 

Menthol, in adenoids, 182 
Mercurial ointment, in treatment 
of syphilis, 211 

Mercurochrome, in treatment of 
otitis media, 188 
Miliaria, 219 
Miliary tuberculosis, 206 
Milk, choice of, 60 

— condensed, 69 

— dried powders of, 69 

— equipment necessary for modi¬ 
fication of, 61 

— frozen, 60 

— in prophylaxis of tuberculosis, 

208 

— method of obtaining from wet- 
nurse, 52 

— of magnesia, see Magnesia, 
milk of 


Milk, protein, 68 
-reenforced, 68 

— relative composition of, 59 

— sterilization of, 60 

— supply not increased by drugs, 
47 

— true, 4 

Mineral oil enema, 90 
Minor ailments, affecting milk 
supply, 49 

— effect on weight, 4 
Mixed feedings, 56 
Modification of milk, equipment 

necessary for, 61 
Morbilli, 142 
Morphin, 97 

— dosage of, 98 

— in cerebrospinal meningitis, 
175 

— in cyclic vomiting, 129 

— in infantile paralysis, 
178 

Mother, care of bowels, 48 

— exercise, 48 

— food, 47 

— mental state, 48 

— minor ailments, 49 

— recreation, 48 

— sleep, 48 

Mouth, cleansing of, 20 
Mouth breathing, cause and re¬ 
sults of, 181 
Mumps, 164 

— complications, 164 

— etiology, 164 

— incubation period, 164 

— quarantine, 165 

— symptoms, 164 

— treatment, 164 

Murphy drip, in cyclic vomiting, 
129 

Muscles, rickets causing loss of 
tone of, 116 
Mustard pack, 89 
Mustard plaster, 89 





INDEX 


254 

Nagging, influence of, 225 
Nails, biting of, 228 

— care of, 22 
Nasal drip, 92 

— in diarrhea, 126 
Nephritis, weaning indicated in, 

54 

Nervous system, tetany a disease 
of, 118 

Neurotic child, 225 

— breath-holding, 229 

— characteristics, 227 

— enuresis, 231 

— environment, 225 

— heredity, 225 

— lisping, 233 

— masturbation, 228 

— nail-biting, 228 

— need of play, 226 

— pica, 234 

— rumination, 229 

— speech defects, 233 

— stammering, 233 

— thumb-sucking, 228 

— tics, 233 

Newborn, diseases of, 103 

-abnormalities, 109 

-asphyxia neonatorum, 103 

-atelectasis, 105 

-birth paralysis, no 

-caput succedaneum, 105 

-cleft palate, 109 

-harelip, 109 

-- hemorrhage due to labor, 

105 

-inanition fever, in 

-'infection, 107 

-inguinal hernia, 109 

-jaundice, 105 

-ophthalmia neonatorum, 106 

-spontaneous hemorrhages, 

106 

-umbilical hernia, 108 

Night clothes, 29 

Nipples, artificial, care of, 64 


Nipples, cracked, treatment of, 49 
Nits, of pediculus capitis, 85, 222 
Nocturnal enuresis, 231 
“Normal” growth, 3 
Normal infant, abdomen, 6 

— airings, 23 

— bath, 18 

— bed, 13 

— birth weight, 3 

— bladder training, 25 

— calories required, 43 

— care at birth, 17 

— chest, 6 

— clothing, 26 

— deciduous teeth, 10, 22 

— development, 7 

— difficult dentition, 10 

— early loss of weight by, 3 

— exercise, 24 

— food requirements of, 43 

— growth of, 3, 4 

— head of, 5 

— hearing, 9 

— height, 5 

—• movements involuntary at 

birth, 7 

— muscular development, 6 

— nails, care of, 22 

— pain, sense of, 9 

— rectum training, 25 

— sight, 9 

— sleep, 12 

— smell, 9 

— speech, 8 

— taste, 9 

— teeth, 9 

— variations in weight, 4 

— walking, 8 

Nose, chest affected by obstruc¬ 
tion of, 6 

— cleansing of, 20 

— hemorrhage from, 106 
Nurse, requirements of, 84 
Nursing, technic of, 49 

— time required for, 50 



INDEX 


Nursing, wet, 51 
Nutrition, in prematurity, 33 
Nux vomica, tincture of, 97, 98 
Nystagmus, in tuberculous men¬ 
ingitis, 176 


Oatmeal water, 67 

— for constipation, 68 
Observations, routine, changes in 

condition, 84 

-eruptions, 85 

-general well-being of pa¬ 
tient, 84 

-parasites, 85 

O’Dwyer apparatus, 157 
Oil, cod liver, antirachitic vita¬ 
mins in, 43, 115 

-dosage of, 98, 117 

-for premature baby, 38 

-in diarrhea, 126 

-in scurvy, 120 

Oil, olive, anointing premature 
baby with, 36, 38 
Ophthalmia neonatorum, 106 

— treatment of, 107 
Opiates, use of, 97 
Opisthotonus, 176 
Orangeade, in convalescence, 239 
Otitis media, 186 

— adenoids complicated by, 182 

— complicating diphtheria, 154 

— complicating measles, 144 

— complications, 187 

— diarrhea complicated by, 124 

— etiology, 186 

— influenza frequently compli¬ 
cated by, 173 

— isolation, 188 

— primary pneumonia compli¬ 
cated by, 198 

— scarlet fever complicated by, 
141 

— secondary pneumonia compli¬ 
cated by, 202 


255 

Otitis media, septic sore-throat 
complicated by, 183 

— symptoms, 186 

— treatment, 187 

Oxygen, for cyanosis in second¬ 
ary pneumonia, 202 


Pack, mustard, preparation of, 
89 

Pain, abdominal, in smallpox, 165 

— sense of, 9 

Paracentesis, in otitis media, 187 
Paralysis, birth, no 
Pancreas, insulin prepared from, 
100 

Paralysis, infantile, see Infantile 
paralysis 

Parasites, routine observation for, 

8S 

— paregoric, 97 

— dosage of, 98 

— in bronchitis, 195 

— in measles, 146 
Parotitis, epidemic, 164 
Pediculosis, 222 
Pediculus capitis, 85, 222 
Peritoneum, injection into, 92 
Peritonitis, septic sore-throat 

complicated by, 183 
Pertussis, 160 
Petticoat, 29 
Pfeiffer bacillus, 171 
Phenacetin, dosage of, 98 

— in follicular tonsillitis, 185 

— in influenza, 173 

— in mumps, 165 

— in septic sore-throat, 183 
Phosphorus, deficient in rickets, 

116 

Physical state, in convalescence, 
237 

Pica, 234 

Pin-worms, causing enuresis, 231 
Pirquet test, 205 



INDEX 


256 

Plaster, mustard, preparation of, 
<89 

Play, in convalescence, 240 

— need of, 226 

Pneumococcic meningitis, 176 
Pneumonia, 195 

— classification, 195 

— a frequent complication of 
whooping-cough, 162 

— influenza complicated by, 172 

— mustard plaster in, 90 

— primary, 196, see also Primary 
pneumonia 

— rickets and, 116 

— secondary, 200, see also Sec¬ 
ondary pneumonia 

— smallpox and, 166 
Poisoning, lead, 234 
Poliomyelitis, acute, 177 
Powders, bath, 22 
Pregnancy, weaning in, 54 
Premature baby, 33 

— bath dispensed with, 38 

— Boston feeder, 34 

— Cod-liver oil for, 38 

— gavage indicated for, 95 

— jacket for, 35 

— maintenance of body tempera¬ 
ture, 34 

— nutrition, 33 

— prevention of infection, 37 

— prognosis, 38 

— pulse counting with stetho¬ 
scope, 80 

— rickets in, 38 

<— routine care of, 37 

— ultraviolet rays for, 38 
Prematurity, 33 

— determined by weight, 3 

— see also Premature baby 
Prevention of infection, 37 
“Prickly heat,” 219 
Primary pneumonia, 196 

— complications, 198 

— crisis and lysis, 198 


Primary pneumonia, etiology, 196 

— prognosis, 198 

— rectal tube for relief of tym¬ 
panites, 199 

— symptoms, 196 

— treatment, 199 
Prolonged indigestion, 126 

— etiology, 127 

— prognosis, 127 

— symptoms, 127 

— treatment, 127 
Proprietary baby foods, 69 
Protein, per cent in milk, 59 

— results of deficiency of, 41 

— sources of, 41 

— stools following excess of, 42 
Protein milk, 68 

— in diarrhea, 125 

— in prolonged indigestion, 128 

— reenforced, 68 
Pseudoparalysis, in scurvy, 119 
Puberty, earlier in girls, 4 
Pulmonary tuberculosis, 207 
Pulse, method of counting, 80 
Pyelitis, a complication of diar¬ 
rhea, 124 

Pyloric stenosis, 129 

— etiology, 130 

— prognosis, 130 

— symptoms, 130 

— treatment, 130 


Quarantine, in cerebrospinal 
meningitis, 175 

— in infantile paralysis, 178 

— in influenza, 173 

— in rubella, 147 

— in scarlet fever, 142 

— in smallpox, 168 

— in whooping-cough, 163 
Quinin, dosage of, 98 

— rectal administration of, 90 

— useless as preventative of 
thumb-sucking, 228 



INDEX 


257 


^Rachitic rosary, 116 
Rales, in bronchitis, 193 
Rash, characteristic in chicken- 
pox, 148 

— in hereditary syphilis, 209 

— in measles, 144 

— in rubella, 147 

— scarlatinal, 140 

— in smallpox, 165 

Ray, Roentgen, in diagnosis of 
rickets, 116 

— ultraviolet, in prematurity, 38 

-in treatment of rickets, 118 

Rectal drip, 92 

Rectal tube, tympanites relieved 
by, 199 

Rectum, irrigation of, 90 

— training of, 25 

Recurrent vomiting, see Cyclic 
vomiting 

Reenforced protein milk, 68 

— in diarrhea, 125 

— in pyloric stenosis, 130 
Respiration, forced, 17, 104 
Respirations, method of count¬ 
ing, 80 

Respiratory diseases, 181 

— adenoids, 181 

— bronchitis, 193 

— croup, 189 

— follicular tonsillitis, 184 

— hypertrophied tonsils, 185 

— otitis media, 186 

— pneumonia, 195 

— septic sore-throat, 183 
Rest, for nursing mothers, 48 

— in convalescence, 238 
Rhubarb, syrup of, 97 

-dosage of, 98 

Rice water, 67 
Rickets, 115 

— adenoids frequent in, 181 

— chest affected by, 6 

— complications, 116 

— dentition delayed in, 11 


Rickets, diagnosis, 116 

— early walking causing strain 
in, 8 

— etiology, 115 

— fontanel closure delayed in, 6 

— in premature baby, 38 

— prognosis, 116 

— prophylaxis, 117 
—’symptoms, 115 

— treatment, 117 

—* ultraviolet rays for prevention 
of, 38 

— vitamin preventing, 43 
Rosary, rachitic, 116 

Routine observations, see Obser¬ 
vations, routine 
Rubella, 146 

— complications, 147 

— diagnosis, 146 

— etiology, 146 

— incubation period, 147 

— quarantine, 147 

— symptoms, 147 

— treatment, 147 
Rubeola, 142 
Rumination, 229 

— vomiting, the result of, 132 
Ruminator cap, 230 


Saline cathartics, decried for 
nursing mothers, 48 
Salt, per cent, in milk, 59 

— solution, hypodermoclysis of, 
9i 

— solution, rectal irrigation with, 
90 

Salts, bone growth promoted by, 
42 

Salvarsan, see Arsphenamin, 211 
Seborrhea, 219 
Secondary pneumonia, 200 

— complications, 202 

— etiology, 200 

— prognosis, 202 



INDEX 


258 

Secondary pneumonia, symptoms, 
200 

— treatment, 202 
Sedatives, use of, 97 
Septic sore-throat, 183 

— complications, 183 

— etiology, 183 

— prognosis, 183 

— symptoms, 183 

— treatment, 183 

Serum, antimeningococcus, 99 

— Flexner’s, 174 

— immune, measles treated with, 
145 

Scabies, 221 
Scalp, edema of, 105 
Scarlatina, 139 
Scarlet fever, 139 

— complications, 141 

— etiology, 139 

—■ incubation period, 140 

— otitis media complicating, 186 

— prognosis, 141 

— quarantine, 142 

— strawberry tongue, 141 

— symptoms, 140 

— tonsils as foci of infection in, 182 

— treatment, 141 
Schick test, 154 
School, Calvert, 241 
Scurvy, 119 

— etiology, 119 

— prophylaxis, 120 

— pseudoparalysis in, 119 

— symptoms, 119 

— treatment, 120 

— vitamins preventing, 43 
Shirt, 29 

Sign, Chvostek’s, 118 

— Erb’s, 118 

— Trousseau’s, 118 
Sight, 9 

Silver nitrate solution, for eyes 
at birth, 17, 170 
“Six-year molars,” n 


“Six-year molars,” cavities in, 23 
Skin, appearance in prematurity, 
33 

— diseases of, 215 

— in inanition fever, hi 

— scurvy causing hemorrhages 
in, 119 

Skull, structure of, 5 
Sleep, 12 

— for nursing mothers, 48 

— hours of, 12 

—■ regular habits for, 12 
Smallpox, 165 

— complications, 166 

— etiology, 165 

— incubation period, 165 

— prognosis, 166 

— quarantine, 167 

— symptoms, 165 

— treatment, 166 

— vaccine, 100, 168 

Smear, vaginal, preparation of 
patient for, 83 
Smell, 9 

“Snuffles,” in hereditary syphilis 
209 

Soap, for bathing infant, 20 
Soap curds, fats causing, 42 
Soapsuds enema, preparation of, 
90 

Sodium bicarbonate, for itching 
in measles, 146 

— lavage of stomach with, 94 
Sodium bromid, dosage of, 98 
Solid food, in mixed feedings, 56 
Solution, boric acid, aural irri¬ 
gation with, 96 

— Dobell’s, in measles, 146 
-in scarlet fever, 142 

— Fowler’s, 97 

— glucose, in acidosis, 125 

-- in cyclic vomiting, 129 

— silver nitrate, 107 
Sore-throat, septic, 183 
Special senses, 8 



INDEX 


Speech, 8 

Speech defects, 233 
Spirochaeta pallida, 208 
Splints, elbow, 217 

-thumb-sucking prevented 

by, 228 

Sponge bath, cool, 21 

— temperature reduced by, 97 
Spontaneous hemorrhages, 106 
Sputum, disposal of, 138 
Stammering, 233 

Steam inhalations, 95, 194 

— in croup, 189 
Stearate of zinc, 22 
Stenosis, pyloric, 129 
Stimulants, use of, 97 
Stomach, vomiting caused by 

overfilling, 132 

Stool, clay-colored in prolonged 
indigestion, 127 

— greenish black, 50 

— method of collecting, 83 

— olive colored in dysentery 
Story-telling, in convalescent, 239 
Strabismus, in tuberculous men¬ 
ingitis, 176 

Strawberry tongue, of scarlet 
fever, 141 

Streptococcus tonsillitis, 183 
Strychnin, 97 

— dosage of, 98 

Sulphur ointment, in treatment 
of scabies, 221 
Summer clothing, 29 
Summer complaint, diarrhea, 123 
Sunshine, during convalescence, 
241 

Supplementary feeding, 56 
Sutures, pliability at birth, 6 
Syphilis, 208 

— acquired, 209 

— dentition often early in, 11 

— forms in childhood, 208 

— hereditary, 209, see also He¬ 
reditary syphilis 


259 

Syrup, of ipecac, in croup, 190 

— of rhubarb, 97 

Taste, 9 

Teeth, at birth, 9 

— care of, 22 

— deciduous, 10 

— influence of thumb-sucking 
upon, 228 

— periodic examination of, 23 

— second set of, 11 

— “wisdom,” 11 
Teething, 9 

— delayed in rickets, 116 
Temperature, drugs for reducing, 

96 

— in cerebrospinal meningitis, 
174 

— in croup, 189 

— incubator for maintenance of, 
34 

— in follicular tonsillitis, 184 

— in inanition fever, no 

— in infantile paralysis, 177 

— in influenza, 172 

— in measles, 143 

— in miliary tuberculosis, 206 

— in otitis media, 187 

— in primary pneumonia, 197 

— in scarlet fever, 140 

— in secondary pneumonia, 200, 
201 

— in smallpox, 165 

— method of taking, 79 

— of bath, 19 

— of fluid for hypodermoclysis, 
9 i 

— of food for gavage, 95 

— of premature baby, 36 

— seldom high in rubella, 147 

— subnormal in prematurity, 33, 
34 

— warm room, 34 

Tent, croup, construction of, 95 



26 o 


INDEX 


Test, Schick, 154 
Tetany, 118 

— Chvostek’s sign, 118 

— Erb’s sign, 118 

— etiology, 118 

— prophylaxis, 118 

— symptoms, 118 

— treatment, 119 

— Trousseau’s sign, 118 
Therapy, of infancy and child¬ 
hood, 89 

Thrush, 20 
Thumb-sucking, 228 
Thyroid extract, in cretinism, 100 
Tics, 233 

Tongue, strawberry, in scarlet 
fever, 141 
Tonics, 97 

Tonsillitis, effect on maternal 
nursing, 49 

— follicular, see Follicular ton¬ 
sillitis 

Tonsils, as foci of infection, 182 

— hypertrophied, see Hypertro¬ 
phied tonsils 

Towels, bath, 19 
Toxin-antitoxin, diphtheria, 155 

-immunity obtained with, 99 

Toys, 227 

— germs harbored in, 138 

— in convalescence, 240 
Tracheotomy, 160 
Transfusion, 93 

— spontaneous hemorrhage treat¬ 
ed by, 106 

Treponema pallida, 208 
Trousseau’s sign, in tetany, 118 
True milk, 4 
Tuberculin test, 205, 208 

— in cows, 60 
Tuberculosis, 205 

— bronchitis complicating influ¬ 
enza causing diagnosis of, 172 

— chest affected by, 6 

— etiology, 205 


Tuberculosis, measles aggravat¬ 
ing, 145 

—• miliary, 206 

— prophylaxis, 207 

— treatment, 208 

— tuberculin test, 205 

— types of, 206, 207 
Tuberculous meningitis, 175 

— etiology, 175 

— eye changes in, 176 

— opisthotonus, 176 

— prognosis, 176 

— symptoms, 175 

— treatment, 176 
Tympanites, relieved by hot water 

bag, 199 

Urine, collection of, 82 

— scanty in pyloric stenosis, 130 
Umbilical cord, hemorrhages 

from, 106 

— management of, 17 
Umbilical hernia, 108 

— in whooping-cough, 162 
Umbilical vein, injection, 106 
Umbilicus, easily infected, 108 
Ultraviolet ray, in prematurity, 38 

— in treatment of eczema, 219 

— in treatment of rickets, 118 

Vaccination, smallpox, 168 
Vaccines, in treatment of furun¬ 
culosis, 221 

— preparation and use of, 100 

— smallpox, 100, 168 
Vagina, examination of, 83 

— smear from, preparation for, 
82 

Vaginitis, causing enuresis, 231 
Variations in weight, 4 
Varicella, 147 
Variola, 165 
Vegetable broth, 70 



INDEX 


261 


“Vernix caseosa,” 17 
Vitamin, 43 

— antirachitic, 115 

— antiscorbutic, 120 

-destroyed by boiling, 61 

Vomiting, cyclic, 128 

— fats causing, 42 

— from excess feeding, 51 

— in diarrhea, 123 

— in influenza, 172 

— in pyloric stenosis, 130 , 

— in smallpox, 165 

— in treatment of croup, 189 

— in tuberculous meningitis, 176 
—• in whooping-cough, 162 

— lavage of stomach in, 94 

— menstruation return causing, 

49 

— other causes of, 131-133 

— recurrent, see Cyclic vomiting 

— reflex, 133 

— scarlet fever initiated with, 140 

— serious sign in diphtheria, 154 

— tables of causes, 131-133 
Von Pirquet test, 205 
Vulva, care of, 20 

Walking, 8 

Wassermann reaction, 210 
Water, amount required, 42 

— and glycerin enema, formula 
for, 90 

— barley, 67 

— for bath, 19 

— oatmeal, 67 

— rice, 67 


Weaning, 54 

— breasts during, 55 

— indications for, 54 

— method of, 55 

— minor ailments, not indication 
for, 49 

Weight, at birth, 3 

— early loss of, 3 

— method of determining, 81 

— variations in, 4 
Wet-nursing, 51 

— selection of nurse, 52 

White precipitate ointment, in 
treatment of impetigo, 220 
Whooping-cough, 160 

— causing umbilical hernia, 108 

— complications, 162 

— effect on weight, 5 

— etiology, 160 

— incubation period, 161 

— pneumonia following, 200 

— prognosis, 162 

— quarantine, 163 

— symptoms, 161 

— treatment, 162 

— tuberculosis complicated by, 
207 

— vomiting in, 133 
“Wisdom teeth,” 11 
Wapping, for examination, 82 

X-ray, in diagnosis of pulmonary 
tuberculosis, 207 

— in diagnosis of rickets, 116 

Zinc, stearate of, 22 


(1) 












